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From Wikipedia, the free encyclopedia Anal fissure Classification and external resources ICD-10 K60.0-K60.2 ICD-9 565.0 DiseasesDB 673 MedlinePlus 001130 eMedicine med/3532 ped/2938 emerg/495 MeSH D005401

An anal fissure is a crack or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on the toilet paper, sometimes in the toilet. If acute they may cause severe periodic pain after defecation [1] but with chronic fissures pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.

• 1 Causes
• 2 Prevention
• 3 Treatment
  • 3.1 Drugs
  • 3.2 Surgical procedures
    • 3.2.1 Lateral internal sphincterotomy
    • 3.2.2 Anal dilation (or dilatation)
• 4 See also
• 5 References
• 6 External links

[edit] Causes

Most anal fissures are caused by stretching of the anal mucosa beyond its capability.

Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection, they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria.[2]

[edit] Prevention

For adults, the following may help prevent anal fissure:

• Avoiding straining when defecating. This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents such as caffeine.[3] Similarly, prompt treatment of diarrhea may reduce anal strain.
• Careful anal hygiene after defecation, including using soft toilet paper and/or cleaning with water.
• In cases of pre-existing or suspected fissure, use of a lubricating ointment (e.g. hemorrhoid ointments) can be helpful.
• In infants, frequent nappy/diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas. In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.

[edit] Treatment

Non-surgical treatment is recommended as first-line treatment of acute and chronic anal fissures.[4][5] Customary treatments include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.

Surgical treatment, under general anaesthesia, was either anal stretch (Lord’s operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general anaesthetic and can be painful postoperatively. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

A new medical/surgical development came in 1993 when researchers reported injecting botulinum toxin into the anal sphincter to relax the sphincter and promote fissure healing.[1]

[edit] Drugs

Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[6][7][8][9] and then calcium channel blockers with in 1999 nifedipine ointment,[10][11] and the following year with topical diltiazem.[12] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is direct injection of botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However it must be noted that, in many cases involving Botox injections the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is cleary the Gold Standard for curing this affliction. [13] Combination of medical therapies may offer up to 98% cure rates.[14]

[edit] Surgical procedures

Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Despite their high success rate (~95%), they are used only after extensive medical treatment has failed due to their potential complications. These include general risks from anesthesia, infection and anal leakage (fecal incontinence). Surgical procedures include sphincterotomy and dilation.

[edit] Lateral internal sphincterotomy

Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area. This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).[15]

[edit] Anal dilation (or dilatation)

Anal dilation, or stretching of the anal canal (Lord’s operation) has fallen out of favour in recent years, primarily due to the perceived unacceptably high incidence of fecal incontinence.[16] In addition, anal stretching can increase the rate of flatus incontinence.[17]

In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects.[18] Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS,[19] while another has again shown high success rates with anal dilation coupled with low incidence of side effects.[20]

[edit] See also

• Hemorrhoid
• Pruritus ani

[edit] References

1. ^ a b Gott, M. D.; Peter, H. (5 March 1998). “New Therapy Coming for Anal Fissures”. The Fresno Bee (Fresno, CA: McClatchy Co): p. E2, “Life” section.
2. ^ Collins, E. E.; Lund, J. N. (September 2007). “A Review of Chronic Anal Fissure Management”. Techniques in Coloproctology 11 (3): 209–223. doi:10.1007/s10151-007-0355-9. PMID 17676270.
3. ^ Basson, Marc D. (28 January 2010). “Constipation”. eMedicine. New York, NY: WebMD. http://emedicine.medscape.com/article/184704-overview. Retrieved 5 April 2010.
4. ^ Nelson, R. (2006). “Non-surgical Therapy for Anal Fissure”. Cochrane Database of Systematic Reviews (4). CD003431.
5. ^ Haq., Z.; Rahman, M.; Chowdhury, R.; Baten, M.; Khatun, M. (2005). “Chemical Sphincterotomy—First Line of Treatment for Chronic Anal Fissure”. Mymensingh Medical Journal 14 (1): 88–90. PMID 15695964.
6. ^ =Loder, P.; Kamm, M.; Nicholls, R.; Phillips, R. (1994). “‘Reversible Chemical Sphincterotomy’ by Local Application of Glyceryl Trinitrate”. British Journal of Surgery 81 (9): 1386–1389. doi:10.1002/bjs.1800810949. PMID 7953427.
7. ^ Watson, S.; Kamm, M.; Nicholls, R.; Phillips, R. (1996). “Topical Glyceryl Trinitrate in the Treatment of Chronic Anal Fissure”. British Journal of Surgery 83 (6): 771–775. doi:10.1002/bjs.1800830614. PMID 8696736.
8. ^ Simpson, J.; Lund, J.; Thompson, R.; Kapila, L.; Scholefield, J. (2003). “The Use of Glyceryl Trinitrate (GTN) in the Treatment of Chronic Anal Fissure in Children”. Medical Science Monitor 9 (10): PI123–126. PMID 14523338. http://www.medscimonit.com/index.php?/archives/article/13258.
9. ^ Lund, J. N.; Scholefield, J.H. (4 January 1997). “A Randomised, Prospective, Double-blind, Placebo-controlled Trial of Glyceryl Trinitrate Ointment in Treatment of Anal Fissure”. The Lancet 349 (9044): 11–14. doi:10.1016/S0140-6736(96)06090-4.
10. ^ Antropoli, C.; Perrotti, P.; Rubino, M.; Martino, A.; De Stefano, G.; Migliore, G.; Antropoli, M.; Piazza, P. (1999). “Nifedipine for Local Use in Conservative Treatment of Anal Fissures: Preliminary Results of a Multicenter Study”. Diseases of the Colon and Rectum 42 (8): 1011–1015. doi:10.1007/BF02236693. PMID 10458123.
11. ^ Katsinelos, P.; Kountouras, J.; Paroutoglou, G.; Beltsis, A.; Chatzimavroudis, G.; Zavos, C.; Katsinelos, T.; Papaziogas, B. (2006). “Aggressive Treatment of Acute Anal Fissure with 0.5% Nifedipine Ointment Prevents Its Evolution to Chronicity”. World Journal of Gastroenteroloogy 12 (38): 6203–6206. PMID 17036396. http://www.wjgnet.com/1007-9327/12/6203.asp. Retrieved 12 May 2009.
12. ^ Carapeti, E.; Kamm, M.; Phillips, R. (2000). “Topical Diltiazem and Bethanechol Decrease Anal Sphincter Pressure and Heal Anal Fissures without Side Effects”. Diseases of the Colon and Rectum 43 (10): 1359–1362. doi:10.1007/BF02236630. PMID 11052511.
13. ^ Jost, W.; Schimrigk, K. (1993). “Use of Botulinum Toxin in Anal Fissure”. Diseases of the Colon and Rectum 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394.
14. ^ Tranqui, P.; Trottier, D.; Victor, C.; Freeman, J. (2006). “Nonsurgical Treatment of Chronic Anal Fissure: Nitroglycerin and Dilatation versus Nifedipine and Botulinum Toxin”. Canadian Journal of Surgery [Journal Canadien de Chirurgie] 49 (1): 41–45. PMID 16524142. http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-49/issue-1/pdf/pg41.pdf. Retrieved 2009-05-12.
15. ^ Wolff, B. G.; Fleshman, J.W.; Beck, D. E.; Church, J. M. (2007). The ASCRS Textbook of Colon and Rectal Surgery. Springer. p. 180. ISBN 9780387248462. http://books.google.com/?id=3dDYW2tbx6UC&pg=PA180&dq=sphincterotomy+incontinence. Retrieved 2009-07-15. [clarification needed]
16. ^ Kotlarewsky, M.; Freeman, J. B.; Cameron, W.; Grimard, L. J. (2001). “Anal Intraepithelial Dysplasia and Squamous Carcinoma in Immunosuppressed Patients” (PDF). Canadian Journal of Surgery (Journal Canadien de Chirurgie) 44 (6): 450–454. PMID 11764880. http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-44/issue-6/pdf/pg450.pdf. Retrieved 2009-05-12.
17. ^ Sadovsky, R. (1 April 2003). “Diagnosis and management of patients with anal fissures – Tips from Other Journals” (Reprint). American Family Physician 67 (7): 1608. http://web.archive.org/web/20080209180657/http://findarticles.com/p/articles/mi_m3225/is_7_67/ai_99410474. Retrieved 2009-05-12.
18. ^ Sohn, M.; Weinstein, M. A. (PDF). Anal Dilatation for Anal Fissures. http://ssamed.com/pdf/presentation_adaf.pdf. Retrieved 2009-07-15.
19. ^ Yucel, T.; Gonullu, D.; Oncu, M.; Koksoy, F. N.; Ozkan, S. G.; Aycan, O. (June 2009). “Comparison of Controlled-intermittent Anal Dilatation and Lateral Internal Sphincterotomy in the Yreatment of Chronic Anal Fissures: A Prospective, Randomized Study”. International Journal of Surgery 7 (3): 228–231. doi:10.1016/j.ijsu.2009.03.006. PMID 19361582.
20. ^ Renzi, A.; Brusciano, L.; Pescatori, M.; Izzo, D.; Napolitano, V.; Rossetti, G.; del Genio, G.; del Genio, A. (January 2005). “Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study”. Diseases of the Colon and Rectum 48 (1): 121–126. doi:10.1007/s10350-004-0780-z. PMID 15690668.

[edit] External links

• “Anal Fissure Blog”. FissureFree.com. http://www.fissurefree.com/blog. Retrieved 2009-11-09. [unreliable source?]
• “Anal Fissure”. Learn Colorectal Surgery. http://www.learncolorectalsurgery.com/Conditions_AnalFissure.php. [unreliable source?] Images, information and podcasts on anal fissure and other colorectal disease.
• “Glossary of Hemorrhoid and Anal Fissure Terms”. http://www.balneol.com/glossary.html. Retrieved 28 March 2008.
• “Anal Fissure Self Help Page”. http://www.boardsailor.com/jack/af/. Retrieved 17 March 2007. [unreliable source?]
• “Anal Fissure Support Forum”. http://analfissure.editboard.com. Retrieved 13 March 2010.
• “Anal Fissure”. Hemorrhoids In Plain English. http://www.hemorrhoidsinplainenglish.com/anorectal/anal-fissure.htm. Retrieved December 15, 2005. [unreliable source?]
• “Anal Fissure”. McKinley Health Center. Urbana, IL: University of Illinois at Urbana–Champaign. http://www.mckinley.uiuc.edu/Handouts/anal_fissure.html. Retrieved 15 December 2005.
• Sokol, Thomas; Marks, Jay W. (ed.). “Anal Fissure”. MedicineNet. New York, NY: WebMD. http://www.medicinenet.com/anal_fissure/article.htm. Retrieved 15 December 2005.
• “What are Anal Fissures?”. Cellegy Pharmaceuticals. Archived from the original on 17 October 2006. http://web.archive.org/web/20061017103240/http://www.cellegy.com/science/anal-fissures.html. Retrieved 15 December 2005. [unreliable source?]

Digestive system  Digestive disease  Gastroenterology (primarily K20–K93, 530–579) Upper GI tract Lower GI tract:
Intestinal/
enteropathy GI bleeding/BIS Accessory Abdominopelvic