GIT J Club anal fissure

1. Kurdistan Board GEH/GIT Surgery J Club 2022
Supervised by Professor Dr. Mohamed Alshekhani.

6. Introduction:
 An otherwise healthy 24 year old schoolteacher presents with a three
month history of sharp, severe anal pain on defecation.
 There is bright red blood on wiping& an intense burning pain that persists
for several hours after bowel movements.
 He is on sick leave because the pain is so extreme.
 An anal fissure is a tear in the skin of the anal canal.
 Anal fissures common,specially in middle aged adults, children& infants.
 Chronic means 4-12 weeks of pain.
 Presentation to primary care is commonly delayed due to embarrassment,
despite the often highly distressing symptoms.
 Topical treatments can be effective, although side effects are common.

7. What to cover:history
 Symptoms of painful defecation rectal bleeding strongly suggestive of AF.
 Conditions may coexist—for example, haemorrhoids&anal fissure.
 The patient’s history should be broad enough to account for this.
 Many differentials share similar presenting features.
 Key to diagnosis is the nature of pain (with or without bleeding)
&relationship to defecation.
 Is defecation painful? Pain from a fissure is typically severe& sharp(
include knife-like, passing broken glass, tearing, or splitting).
 A burning pain may persist for several hours after defecation.
 Consider underlying causes if: unintentional weight loss, a change in bowel
habit, tenesmus, loss of appetite, abd pain, fevers, night sweats, rashes,
family& sexual history.
 Primary causes are usually the result of local trauma (including
constipation) rather than an underlying medical condition.
 Secondary causes are less common& improve as the underlying medical
condition improves.

8. What to cover:history
 Is there rectal bleeding? Bright red blood on wiping or on the surface of
the stool often occurs with a fissure.
 Other types of bleeding, as darker blood or blood mixed with the stool,
may indicate a more proximal cause (such as colitis or cancer).
 Some (as those who require help with personal care or visual impairment)
may be unaware of bleeding& a collateral history may be useful.
 How long have symptoms been present? Most acute fissures heal within
one to two weeks&chronic fissure means 4-12 weeks of symptoms.
 Is there incontinence? Continence is not usually affected.
 Establish baseline continence to guide future management options.
 Has this happened before? To identify patients who needed referral for
recurrent anal fissure, may be a sign of an underlying cause as IBD.
 Impact have symptoms on QOL&mental health as may be affected.
 Fearful of pain, patients may avoid opening their bowels, predisposing to
constipation&a vicious cycle.
 Pain may make it difficult to work,exercise, socialise, or even sit.

9. What to cover:Exam
 Explain that symptoms may be due to an anal fissure—a tear at the edge of
the anus& exam can help confirm this. Seek consent& offer a chaperone.
 During the initial assessment, inspect the perianal area.
 If there are no red flags&symptoms are typical of a fissure, we recommend
deferring DRE(to exclude other serious anorectal conditions) to a follow-
up appointment when the patient’s pain has improved.
 Acute fissure is superficial laceration, well demarcated edges (paper cut),
chronic fissures are wider& deeper,have raised edges that may be swollen.
 Sphincter muscle fibres may be visible at the base of a chronic fissure.
 At the proximal end of a chronic AF may be hypertrophied anal papillae,
& at the distal margin may be a skin tag (sentinel pile).
 Primary, or typical, fissur usually singular,generally in the posterior
midline ;less commonly in the anterior midline,more so in women.
 Atypical(multiple, lateral or irregular borders) indicate a secondary cause.
 Anal spasm&/or pain may make it difficult to visualise the fissure.
 Strain reveal the fissure but gentle pressure on anal margin produce pain.

10. Management:general
 For patients with a chronic anal fissure who are unlikely to have a
secondary cause, explain what an anal fissure is& how they come about.
 We explain a fissure is a tear in the lining of the anus, that the underlying
cause is usually unclear, but may be related to local trauma caused by
constipation or diarrhoea, although in many cases neither of these are
present.
 We emphasise the vicious circle of pain/spasm, which prevent healing.
 Hence, the aims of treatment are to relieve spasm&improve blood supply
to the fissure, which should help alleviate symptoms & heal the fissure.

11. Management:dietary/life style
 These should continue long term.
 Stool should be soft, passed easily without straining.
 Suggest minimising delay between getting the urge to defecate& going to
the toilet.
 Not more time than is needed should be spent on the toilet.
 Recommend regular exercise (150 minutes of moderate intensity activity
/week), weight management (if relevant), good hydration& balanced
diet,including adequate dietary fibre (30 g a day for adults).
 Highlight that soluble fibre is good for constipation, but fibre in general
also reduces risk of a range of illnesses, including CVD,T2DM,CRC&BC
 Increase fibre intake gradually to avoid flatulence/ bloating.
 Sitting in a warm, shallow bath that bathes the perineum (sitz bath) is
often recommended, but evidence is weak, bidets, or therapeutic local heat
may be more practical, but data also lacking.

12. Management:drugs
 Topical lidocaine may relieve pain on defecation in 30 mins but no long use
 Suggest regular paracetamol&/or ibuprofen for post-defecatory pain.
 Avoid opioids ( as codeine and tramadol) as they cause constipation, unless
pain cannot be managed with the aforementioned measures.

13. Management:diltiazem
 The AC of Great Britain& Ireland&AS of Colon/Rectal Surgeons
recommend topical diltiazem as the first line pharmacological agent
 The course is 8 Ws ,Diltiazem cause perianal itch, dermatitis& headache,
but headache is 85% less&better tolerated,it should be refrigerated&used
within 4 wks of opening (so 2 tubes needed),not so for GTN.

14. Management:GTN
 GTN causes systemic side effects while local diltiazem causes local side
effects.
 NICE suggests GTN 0.4% ointment as first line trt in adults who have had
symptoms of primary AF for ≥1 wk without improvement
 GTN causes headache, paracetamol before applying it& applying it with
clingfilm wrapped around the finger to reduce absorption.

15. Management:Botox inj
 Botox acts at the level of the motor endplate by blocking the presynaptic
reuptake of acetylcholine with action on striated&smooth muscles.
 It is mor effective than nitrates, with an improved cure rate & lower
recurrence rate at 1 year (28% versus 50%) but higher cost,less effective
than LIS but has a lower risk of AI.
 It is reserved for patients with one or more surgical contraindications or
those with a high risk of AI.
 The effectiveness does not depend on the dose(10 to 100 IU), the volume,
site(frequently located between 3&9 o’clock in the pectoral knee position
or on either side of the AF , the number of injections, or type(Botox or
Dysport.
 The ACGBI guidelines propose use in cases of AFs resistant to local trt.

16. Management:follow up.
 We recommend reviewing all patients with anal fissure no later than 6-8
weeks after start of treatment, to ensure that symptoms have resolved& to
re-examine the perianal area&conduct DRE(especially if this was not done
at the first visit) to help confirm that the fissure has resolved&to assess for
any coexisting anorectal pathology.
 If primary fissure is confirmed, non-healing AF may require botulinum
toxin injection.
 The operative management of anal fissure is reviewed elsewhere.

17. Management : Investigations & referral.
 Investigations in secondary care depend on the clinical scenario but may
include colonoscopy, flexible sigmoidoscopy, exam under anaesthesia,
biopsy& culture.
 Consider referral for:
 Elderly(in whom primary fissures are uncommon&there is higher chance
of malignant causes).
 Patients with non-healing or recurrent fissures.
 Atypical features(lateral location, irregular margins, multiple fissures), or
red flags.
 Patients who have tried topical treatment for 6-8 wks without adequate
response.