tag:blogger.com,1999:blog-35277082745589216552024-02-19T18:51:04.457+05:30Fissure in AnoAbout anal fissure, medical treatment for anal fissure, butox injection for anal fissure, surgery for anal fissure, lateral sphincterotomy for anal fissure, anal stretch and anoplasty for fissures. Pradeep Saxenahttp://www.blogger.com/profile/04464459262599710508noreply@blogger.comBlogger1125tag:blogger.com,1999:blog-3527708274558921655.post-48281823989436942152012-11-10T21:03:00.000+05:302016-06-27T23:31:02.697+05:30Anal fissure<div dir="ltr" style="text-align: left;" trbidi="on">
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<b><span style="font-family: "arial" , "sans-serif";">What is an anal fissure?</span></b></div>
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 10pt;">An<span class="apple-converted-space">al
fissures are a break or tear</span> in the skin of the </span><span style="background: white; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">anal
canal, usually seen as a linear ulcer at the anal verge. Anal fissures are most commonly located posteriorly in the
midline [6 o clock position], but may be sometimes anteriorly at 12 o clock
position. Lateral fissures are also seen sometimes and may be associated with
underlying intestinal diseases like tuberculosis or inflammatory bowel disease.
Acute fissure may be a superficial erosion of the anal mucosa. Chronic fissures
are deep down to the internal anal sphincter muscle and usually accompanied
with hypertrophied anal papillae and a sentinel tag. The internal sphincter
muscle of anal canal is usually in spasm and thus the fissures are painful.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">They occur equally frequently
in men and women and most often occur in young adults. </span><span style="background: white; font-family: "arial" , "sans-serif"; font-size: 10.0pt;"><o:p></o:p></span></div>
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<b><span style="background: white; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Symptoms
of anal fissure<o:p></o:p></span></b></div>
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<span style="background-color: white; font-family: "arial" , sans-serif; font-size: 10pt;">Acute fissures cause<span class="apple-converted-space"> </span></span><span style="background: white; font-family: "arial" , "sans-serif"; font-size: 10.0pt;">pain<span class="apple-converted-space"> during and </span>after defecation [painful or difficult evacuation]. Anal
fissures may also cause bright red anal bleeding on the toilet. Blood may be
seen alongside of the stools while defecation. In chronic fissures pain is less
intense. Chronic fissures may cause mucous discharge, soiling of the
undergarment and pruritis in the anal region.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 14.5pt;">Causes</span><span style="font-family: "arial" , sans-serif; font-size: 14.5pt;"><o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Most anal fissures are caused by overstretching of the anal mucosa beyond
its capacity. In adults, fissures may be caused by constipation, passing of
large, hard stools, by prolonged diarrhea or due to anal sex. In older adults,
anal fissures may be caused by decreased blood flow to the area.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">It has been seen that fissures are associated with <b>increased resting anal pressure</b> due to <b>spasm of internal sphincter muscle</b> of
anal canal. The most common reason for development of fissure is spasm of the
internal sphincter muscle of anal canal. Sphincter spasm results in
impaired blood supply to the anal mucosa. The result is a non-healing ulcer,
which may become infected by fecal bacteria. Resting pressures of anal canal in
patients with fissures are twice as high as normal subjects. Restoration of
anal canal pressure by lateral sphincterotomy is associated with improvement of
symptoms and healing of fissures in 98% of patients.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Other causes of anal fissures include:<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Poor toileting in young children.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Childbirth trauma in women.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Inflammatory bowel disease [crohn’s disease or
ulcerative colitis], tuberculosis, gonorrhea, syphilis, herpes and AIDS.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Fissures may be associated with leukemia, underlying
cancer of anal canal/ rectum etc.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Anal sex.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 14.5pt;">Prevention</span><span style="font-family: "arial" , sans-serif; font-size: 14.5pt;"><o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">High fiber diet.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Avoiding constipation and straining when
defecating.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Prompt treatment of diarrhea may reduce anal
strain.<o:p></o:p></span></div>
<div class="MsoNormal" style="background: white; line-height: 14.4pt; margin-bottom: 1.2pt; margin-left: 19.2pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list .5in; text-indent: -.25in;">
<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Maintaining cleanliness and good anal hygiene. Using
soft toilet paper or cleaning with water.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Frequent diaper changes and keeping
the area dry can prevent anal fissure in newborn and children.<o:p></o:p></span></div>
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<!--[if !supportLists]--><span style="font-family: "wingdings"; font-size: 10pt;">§<span style="font-family: "times new roman"; font-size: 7pt; line-height: normal;"> </span></span><!--[endif]--><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Avoid coffee, alcoholic beverages, smoking and
spicy food.<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 14.5pt;">Treatment</span><span style="font-family: "arial" , sans-serif; font-size: 14.5pt;"><o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Superficial anal fissures will often heal within a few weeks on
conservative management. However anal fissures which are deep and become
chronic will not heal spontaneously, and may require medications or surgery.<o:p></o:p></span></div>
<h2>
Medical management
of fissure<o:p></o:p></h2>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">General measures like warm sitz bath, topical anesthetic
agents, stool softeners and high fiber diet are usually advised. <o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Non-surgical treatments to reduce resting anal pressure may be tried
initially. These include <b>topical ointments</b>
[nitroglycerine or nifedepine or diltiazem]. Local application of these
ointments will relax the sphincter muscle and thus allow the fissure to heal. A
common side effect and drawback of nitroglycerine and other ointments is
headache, which limits patient acceptability. Topical ointments used for
relaxation of anal sphincter may result in healing of acute fissures in 50 -
75% of patients but carries a high recurrence rates. <o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Injection of </span><b><span style="font-family: "arial" , "sans-serif"; font-size: 10.0pt;">botulinum toxin (Botox)</span></b><span style="font-family: "arial" , sans-serif; font-size: 10pt;"> into the anal sphincter to relax it is another treatment
for anal fissures, used by colorectal surgeons. However, in many cases of Botox
injections the patients eventually had to undergo surgery as the injection
failed to cure the fissure. The success rate for botox injection is 75% at the
end of one year and drops to 55% on long term follow up. Side effects of botox
include urinary retention, heart block, muscle weakness, postural hypotension
and allergic skin reactions.<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif; font-size: 13pt;"><a href="http://www.bhopalsurgery.com/home/patient-information" target="_blank">Surgery for Fissure</a><o:p></o:p></span></b></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">Various surgical options used for treatment of anal fissures are:<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">[1] Anal stretch<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">[2] Lateral sphincterotomy [open or closed]<o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">[3] Anoplasty [V-Y Advancement flap] <o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Anal sphincter stretch </span></b><span style="font-family: "arial" , sans-serif; font-size: 10pt;">is done to disrupt the sphincter fibers and reduce
the resting anal pressure. It is associated with anal incontinence in a small
proportion of cases and has been given up by most of the surgeons. Anal stretch
should be avoided in women and elderly patients because of increased likelihood
of incontinence. <o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Lateral sphincterotomy</span></b><span style="font-family: "arial" , sans-serif; font-size: 10pt;"> is presently the </span><span style="font-family: "arial" , "sans-serif"; font-size: 10.0pt;">Gold Standard treatment for curing
anal fissures associated with high resting anal pressures, chronic anal
fissures and fissures associated with underlying fistula. In this procedure the
internal anal sphincter muscle is partially divided in order to reduce spasm.
This results in decrease in resting anal pressure and improvement of the blood
supply. The sentinel pile and hypertrophied anal papillae are also excised. Lateral
sphincterotomy is considered as a superior method of treating anal fissures
because it has a higher rate of fissure healing [98%], fewer side effects and
better long term symptomatic improvement.<o:p></o:p></span></div>
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<b><span style="font-family: "arial" , sans-serif; font-size: 10pt;">Anoplasty [V-Y
Advancement flap]</span></b><span style="font-family: "arial" , sans-serif; font-size: 10pt;"> is used for treatment
of fissures associated with anal stenosis and fissures with normal resting anal
pressure. <o:p></o:p></span></div>
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<span style="font-family: "arial" , sans-serif; font-size: 10pt;">These operations may be done as </span><a href="http://www.bhopalsurgery.com/services/day-care-surgery" target="_blank"><span style="font-family: "arial" , "sans-serif"; font-size: 10.0pt;">day care surgery</span></a><span style="font-family: "arial" , sans-serif; font-size: 10pt;"> under local or general anesthesia. <o:p></o:p></span></div>
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