By ALLEN P. KONG, MD and MICHAEL J. STAMOS, MD |
June 1, 2005
University of California, Irvine
Dr Kong is a third-year surgical resident at the University of California, Irvine Medical Center. Dr Stamos is professor of clinical surgery and chief of the division of colon and rectal surgery at the same institution.
Anal fissures are linear ulcerations of the distal anal canal anoderm (Figure 6). Fissures often result from difficult, traumatic bowel movements. Patients with chronic anal fissures frequently have elevated resting anal pressures; the increased pressure leads to decreased anodermal blood flow and local ischemia—especially at the posterior midline, where there is a paucity of vessels.
Symptoms and physical findings. Symptoms may include burning or aching pain that occurs during—and especially after—bowel movements; bleeding; spasm; and fecal soiling. Patients may fear having a bowel movement. Digital evaluation reveals increased anal sphincter tone.
The majority of fissures appear as anodermal defects located in the posterior midline, although 10% of women and 1% of men have anterior fissures. An associated "sentinel pile" or sentinel skin tag can often be seen at the distal or caudal extent of the fissure (see Figure 6); this represents fibrosis and excess granulation from the ulceration. These skin tags are frequently mistaken for hemorrhoids; however, a midline location—especially of an isolated skin tag—helps rule out symptomatic hemorrhoids. Fissures that are unusual in appearance or location may be associated with Crohn disease, malignancy, tuberculosis, syphilis, Cytomegalovirus infection, or HIV infection.
Management. Medical therapies for anal fissures include avoidance of straining or heavy lifting, warm baths, psyllium(Drug information on psyllium) or other bulking agents, topical anesthetics/analgesics, chemical sphincterotomy (by nitroglycerin 0.2% ointment3 or diltiazem 2% gel,4 applied with a gloved finger 2 or 3 times daily for 6 weeks), and injection with botulinum toxin. Anal fissures often resolve within 6 weeks of initiation of treatment; however, recalcitrant fissures may require surgical intervention (either lateral internal sphincterotomy or fissurectomy and sphincterotomy with anoplasty).5
Anorectal Complaints: Office Diagnosis and Treatment, Part 2
- Hemorrhoids are consistent in anatomic position: left lateral, right posterior,
or right anterior.
- An emerging conservative therapy for thrombosed external hemorrhoids
is twice-daily application of topical 0.3% nifedipine. This calcium
channel blocker decreases the tonicity of the internal anal sphincter, a
proposed contributor to the pain of thrombosed external hemorrhoids.
- Because the columnar mucosa involved in internal hemorrhoids lacks
nerve endings, pain is typically not present. If a patient with enlarged
internal hemorrhoids complains of pain, look for another source.
- Although the majority of anal fissures are located in the posterior midline,
10% of women and 1% of men have anterior fissures.
- The skin tags associated with anal fissures are frequently mistaken
for hemorrhoids. However, a midline location—especially of an isolated
skin tag—helps rule out symptomatic hemorrhoids.
- Anal fissures that are unusual in appearance or location may be associated
with Crohn disease, malignancy, tuberculosis, syphilis, Cytomegalovirus
infection, or HIV infection.
REFERENCES: Hicks TC, Stamos MJ. Practical approaches to common anorectal problems. Patient Care. Sept 1998;24-51.Loder PB, Kamm MA, Nicholls RJ, Phillips RK. Haemorrhoids: pathology, pathophysiology and etiology. Br J Surg. 1994;81:946-954.
1. Penotti P, Antropolic C. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001;44:405-409.
2. Dixon MR, Stamos MJ, Grant SR, et al. Stapled hemorrhoidectomy: a review of our early experience. Am Surg. 2003;69:862-865.
3. Dorfman G, Levitt M, Platell C. Treatment of chronic anal fissure with topical glyceryl trinitrate. Dis Colon Rectum. 1999;42:1007-1010.
4. Carapeti EA, Kamm MA, Evans BK, et al. Diltiazem lowers resting anal sphincter pressure. A potential low side-effect alternative to glyceryl trinitrate (GTN) for fissures. Gut. 1998;42(suppl 1):A97.
5. Gordon PH, Vasilevsky CA. Symposium on outpatient anorectal procedures. Lateral internal sphincterotomy: rationale, technique, and anesthesia. Can J Surg. 1985;28:228-230.
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