Anal fissure: Difference between revisions
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==Background==
<languages/>
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==Background== <!--T:1-->
 
<!--T:2-->
[[File:Human anus-en.png|thumb|Anatomy of the anus.]]
[[File:Gynecological diagnosis (1910) (14798113703).jpg|thumb|Anatomy of anal fissure.]]
*Superficial linear tear of anal canal from at/below dentate line to anal verge
*Superficial linear tear of anal canal from at/below dentate line to anal verge
**May be due to passage of hard stool, frequent diarrhea, or abuse
**May be due to passage of hard stool, frequent diarrhea, or abuse
*Most common cause of painful rectal bleeding
*Most common cause of painful rectal bleeding
*In >90% of cases anal fissures occur in the midline posteriorly
*In >90% of cases anal fissures occur in the midline posteriorly
**Nonhealing fissure or one not located in midline suggests alternative dx
**Non-healing fissure or one not located in midline suggests alternative diagnosis (e.g. Crohn's, malignancy)
 


==Clinical Findings==
==Clinical Findings== <!--T:3-->
 
<!--T:4-->
[[File:Anal fissure 2.jpg|thumb|Close up photo of anal fissure (at red arrow).]]
*Acute sharp, cutting pain most severe during and immediately after bowel movement
*Acute sharp, cutting pain most severe during and immediately after bowel movement
**Subsides between bowel movements (distinguishes fissure from other anorectal disease)
**Subsides between bowel movements (distinguishes fissure from other anorectal disease)
*Bright red bleeding, small in quantity (usually noticed only on toilet paper)
*Bright red [[Special:MyLanguage/rectal bleeding|rectal bleeding]], small in quantity (usually noticed only on toilet paper)
* Lateral to anus often indicates associated systemic illness such as Crohns, HIV, Leukemia, TB, syphillis
*Lateral to anus often indicates associated systemic illness such as [[Special:MyLanguage/Crohn's|Crohn's]], [[Special:MyLanguage/HIV|HIV]], [[Special:MyLanguage/leukemia|leukemia]], [[Special:MyLanguage/TB|TB]], [[Special:MyLanguage/syphilis|syphilis]]


==Diagnosis==
*Having pt bear down may make fissure more noticable
*Sentinel pile, located at distal end of fissure, along w/ deep ulcer suggests chronicity
**Often misdiagnosed as an external hemorrhoid


==Differential Diagnosis==
==Differential Diagnosis== <!--T:5-->
*[[Crohn Disease]]
 
*Squamous cell carcinoma of anus
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*Adenocarcinoma of rectum invading the anal canal
*Syphilitic fissure
*[[GC]]/Chlam
{{Anorectal DDX}}
{{Anorectal DDX}}
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</translate>
{{Lower GI bleeding DDX}}
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==Evaluation== <!--T:6-->
===Workup=== <!--T:7-->
<!--T:8-->
*Typically clinical (no studies needed)
===Diagnosis=== <!--T:9-->
<!--T:10-->
*Having patient bear down may make fissure more noticable
*Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity
**Often misdiagnosed as an external [[Special:MyLanguage/hemorrhoid|hemorrhoid]]
==Management== <!--T:11-->
<!--T:12-->
*Warm sitz baths 15 min TID-QID and after each bowel movement
**Provides symptomatic relief by improving anal blood flow and relieves anal sphincter spasm
*Topicals
**Pain control with [[Special:MyLanguage/lidocaine|lidocaine]]
**Vasodilators such as [[Special:MyLanguage/nitroglycerin|nitroglycerin]] or [[Special:MyLanguage/nifedipine|nifedipine]] ointment
**[[Special:MyLanguage/Hydrocortisone|Hydrocortisone]]
*High-fiber diet
**Prevents stricture formation by providing a bulky stool
*Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
*Surgical referral indicated if healing does not occur in a reasonable amount of time
==Complications== <!--T:13-->
<!--T:14-->
*[[Special:MyLanguage/Anorectal abscess|Anorectal abscess]]
==Disposition== <!--T:15-->
<!--T:16-->
*Most patients can be managed medically and discharged with outpatient follow-up
==See Also== <!--T:17-->
<!--T:18-->
*[[Special:MyLanguage/Anorectal Disorders|Anorectal Disorders]]
==External Links== <!--T:19-->
<!--T:20-->
*[https://www.merckmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/anal-fissure?query=anal%20fissure Merk Manual - Anal Fissure]
*[https://emottawablog.com/2019/10/the-bottom-line-hemorrhoids-and-anal-fissures-in-the-ed/ EM Ottawa - Hemorrhoids and Anal Fissures in the ED]


==Treatment==
#Hot sitz baths 15 min TID-QID and after each bowel movement
##Provides symptomatic relief and relieves anal sphincter spasm
#Topicals
##Pain control with lidocaine
##Vasodilators such as nitroglycerin ointment
##Hydrocortizone
#High-fiber diet
##Prevents stricture formation by providing a bulky stool
#Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
#Surgical referral indicated if healing does not occur in a reasonable amount of time


==Complications==
==References== <!--T:21-->
#Perianal abscess
#Intersphincteric abscess


==See Also==
<!--T:22-->
*[[Anorectal Disorders]]
<references/>


==Source==
Tintinalli


<!--T:23-->
[[Category:GI]]
[[Category:GI]]
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Latest revision as of 20:29, 6 January 2026

Other languages:

Background

Anatomy of the anus.
Anatomy of anal fissure.
  • Superficial linear tear of anal canal from at/below dentate line to anal verge
    • May be due to passage of hard stool, frequent diarrhea, or abuse
  • Most common cause of painful rectal bleeding
  • In >90% of cases anal fissures occur in the midline posteriorly
    • Non-healing fissure or one not located in midline suggests alternative diagnosis (e.g. Crohn's, malignancy)


Clinical Findings

Close up photo of anal fissure (at red arrow).
  • Acute sharp, cutting pain most severe during and immediately after bowel movement
    • Subsides between bowel movements (distinguishes fissure from other anorectal disease)
  • Bright red rectal bleeding, small in quantity (usually noticed only on toilet paper)
  • Lateral to anus often indicates associated systemic illness such as Crohn's, HIV, leukemia, TB, syphilis


Differential Diagnosis

Anorectal Disorders

Non-GI Look-a-Likes

Undifferentiated lower gastrointestinal bleeding


Evaluation

Workup

  • Typically clinical (no studies needed)


Diagnosis

  • Having patient bear down may make fissure more noticable
  • Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity


Management

  • Warm sitz baths 15 min TID-QID and after each bowel movement
    • Provides symptomatic relief by improving anal blood flow and relieves anal sphincter spasm
  • Topicals
  • High-fiber diet
    • Prevents stricture formation by providing a bulky stool
  • Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
  • Surgical referral indicated if healing does not occur in a reasonable amount of time


Complications


Disposition

  • Most patients can be managed medically and discharged with outpatient follow-up


See Also


External Links


References

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