Anal fissure: Difference between revisions
(Text replacement - " dx" to " diagnosis") |
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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 | **Nonhealing fissure or one not located in midline suggests alternative diagnosis | ||
==Clinical Findings== | ==Clinical Findings== | ||
Revision as of 17:47, 30 July 2016
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
- Nonhealing fissure or one not located in midline suggests alternative diagnosis
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 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
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
- 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
- Perianal abscess
- Intersphincteric abscess