Anal fissure: Difference between revisions

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*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==
*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 [[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 [[Crohn's]], [[HIV]], [[leukemia]], [[TB]], [[syphilis]]


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


==Differential Diagnosis==
==Differential Diagnosis==
{{Anorectal DDX}}
{{Anorectal DDX}}
{{Lower GI bleeding DDX}}
{{Lower GI bleeding DDX}}


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


==Complications==
==Complications==
#Perianal abscess
*[[Anorectal abscess]]
#Intersphincteric abscess


==See Also==
==See Also==

Revision as of 18:59, 29 September 2019

Background

  • 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

  • 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

Evaluation

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

Differential Diagnosis

Anorectal Disorders

Undifferentiated lower gastrointestinal bleeding

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

See Also

References