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 | ||
** | **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 | *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 | *Having patient bear down may make fissure more noticable | ||
*Sentinel pile, located at distal end of fissure, along | *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== | ||
*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 [[lidocaine]] | |||
**Vasodilators such as [[nitroglycerin]] or [[nifedipine]] ointment | |||
**[[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== | ==Complications== | ||
*[[Anorectal 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
- Often misdiagnosed as an external hemorrhoid
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Hemorrhoids
- Pedunculated polyp
- Pilonidal cyst
- Proctitis
- Pruritus ani
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
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
- Pain control with lidocaine
- Vasodilators such as nitroglycerin or nifedipine ointment
- 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