What Are Anal Fissures?

Basic Information

English name: anal fissure
Visiting department: surgical

Common causes: Decreased skin elasticity of the anal canal, impaired blood supply, anal injury, constipation, etc.
Common symptoms: Anal fissures are mainly manifested by anal pain, blood in the stool, and constipation

Causes of anal fissure

Abnormal stool

Anal fissures are first caused by impact or friction from external forces. If the stool is too thick and hard, then the anus is poorly adapted, which will cause the anal canal to crack. Some studies have found that not only constipation, but also diarrhea can produce anal fissures, which can account for 4% to 7% of the causes of anal fissures.

2. Internal sphincter spasm

Inflammatory irritation of the intestine, anal canal or anal sinus, acidic stool excretion, exposed sphincter, angry anger and other abnormal emotions can cause high tension in the anal sphincter, which can cause the resting pressure of the anal canal to increase significantly. Not enough, as hard dung passes, cracks occur.

3. Anatomical defects

The external anal sphincter forms two triangular fissures before and after the anal canal, which lacks sufficient support for the anal canal, but it can produce fissures when it strikes. At the same time, the anal arteries are distributed from both sides to the middle and cross the anus front and back. As a result, two weakly distributed areas are formed before and after the anus, resulting in poor blood supply in this area. The anal canal and rectum extend at a 90-degree angle, and the anal canal bears the greatest pressure during defecation, so the anal fissure is most likely to occur at the midline.

Anal fissure clinical manifestations

The typical clinical manifestations of anal fissure are pain, blood in the stool, and constipation.

Pain

It is the main symptom of anal fissure. The degree and duration of pain herald the severity of the anal fissure. A typical anal fissure pain cycle is: pain-remission-peak-relief-re-pain. Feces stimulate the nerve endings of the ulcer surface during defecation, causing severe burning or knife-like pain after defecation, which can be radiated to the hips, perineum, tail of the palate, or inside the thighs, which is called pain during defecation. Pain relief after a few minutes in the stool, this period is called the pain interval. Later, due to internal sphincter spasm, severe pain occurred for several minutes or hours. At this time, the patient would be restless and unbearable. After the sphincter was fatigued, the muscles were relaxed and the pain gradually eased. After defecation again, the pain recurred.

Blood in the stool

It is mainly bleeding during defecation or wiping blood on the paper after defecation. The blood color is bright red. The amount of bleeding is related to the depth and size of the crack, but it does not spray like hemorrhoids, and rarely bleeds. Anal fissure blood will also recur periodically.

3. Constipation

Many patients with anal fissure have constipation. Some patients suffer from defecation due to anal pain after anal fissure. The feces become harder over time, and constipation can make anal fissure worse, so a vicious cycle is formed.

Anal fissure examination

Anal fissure examination is also very simple, does not require special equipment, and can be completed in the anorectal clinic. However, it should be noted that it can be seen and touched, but do not use an anoscope randomly, to avoid causing greater pain and laceration of the patient.

Look at

(1) Patients with "sentinel hemorrhoids" anal fissures usually have long skin on the front and back of the anal margin. This is clinically known as "sentinel hemorrhoids" and is one of the important signs of anal fissures.

(2) Looking at the rift is located in the middle of the front and back of the anus. You need to pull the anus gently to see it. See if the crack is fresh and how deep it is. Sometimes you can see that the inside of the cleft is white, which indicates that it is deep and has cracked to the fascial tissue on the surface of the internal sphincter.

Touch

Digital diagnosis of anal fissure must be light, gentle and soft.

(1) Feeling the tension of the anal canal Put a lot of lubricating oil on the fingertips, put it gently into the anal canal, and feel the tension of the anal canal to judge the severity of anal fissure. The anal canal is too tense and should be treated even if there is no crack.

(2) Touch the scar tissue and fistula. The severity of the scar tissue indicates the course and prognosis of anal fissure. Subcutaneous fistula with anal fissure also needs to be diagnosed by digital diagnosis.

(3) Touching the anal nipples Patients with anal fissures should not use anal mirrors as much as possible. You can use your fingers to check whether there is an anal nipple hypertrophy.

Anal fissure diagnosis

It is not difficult to diagnose based on medical history, typical clinical symptoms, and findings during examination. If the edge of the anal fissure is soft and neat, there is no scar on the bottom, the color is reddish, and bleeding is easy, indicating an acute anal fissure. If there is a scar around the cleft, the depth of the bottom is not uniform, it is gray-white, and it is not easy to bleed.

Anal fissure treatment

Most patients with chronic anal fissure correct primary constipation or diarrhea, or clinical treatment with topical clinical trials. Patients with poor conservative treatment may consider anal fissure resection and / or lateral sphincterotomy. Acute or first-time anal fissure can be cured by increasing fiber and water intake and warm water sitting bath.

1. Correct abnormal bowel movements

Constipation is one of the main symptoms of anal fissure, and it is also the main cause of anal fissure formation. You can soften your stools by adding dietary fiber food or vitamin supplements to keep the stools open. For constipation, probiotics can be added with laxative drugs.

2. Clean the anus and take a bath

Sit in warm potassium permanganate water at 1: 5000 after defecation or before going to bed to keep the area clean.

3. Topical drug treatment

(1) Analgesics Anesthetics (such as lidocaine gel) and non-steroidal anti-inflammatory drugs (such as diclofenac cream, ibuprofen cream, etc.) can reduce pain symptoms.

(2) Healing hemorrhoid cream and recombinant human epidermal growth factor.

(3) Local application of nitroglycerin cream Apply 0.2% nitroglycerin cream to the anal fissure twice / d for 5 to 8 weeks. The drug can inhibit neurotransmitters and relax smooth muscles and expand blood vessels. Relax the internal sphincter, reduce the pressure in the anal canal, and improve local blood circulation.

(3) Local injection of botulinum toxin A small dose of toxin can weaken the sphincter tone. Injecting 0.1ml of diluted botulinum toxin through the external sphincter near the anal fissure causes chemical denervation and local muscle paralysis, thereby reducing muscle tension.

4. Anal expansion

Applicable to patients with acute or chronic anal fissures without concurrent nipple hypertrophy and sentinel hemorrhoids. Dilating the anus with a finger or a device (can use a bell mouth anoscope that is commonly used in the anorectal department), has a certain effect on alleviating severe anal pain, but it will recur, and may be accompanied by anal hematoma, bleeding, anal incontinence and other adverse reactions in a short time.

5. Surgical treatment

Applicable to patients with chronic anal fissure with anal fissure triad or non-surgical treatment. Commonly used techniques include anal fissure resection and lateral internal sphincterotomy.

Anal fissure prevention

It's important to stay relaxed and happy. The treatment and prevention of constipation is the most important way to prevent recurrence of anal fissure. Pay attention to the cleanliness of the anus, and develop the sanitary habit of cleaning the anus in time after defecation. There are perianal inflammatory diseases such as anus sinusitis, anal papillitis, perianal eczema, and perianal skin diseases. Doing this can effectively prevent the occurrence and recurrence of anal fissure.

Anal fissure reference

[1] Wang Yanmei. Clinical observation on 340 cases of old anal fissure treated by internal anal canal lysis and pathological tissue resection [J]. Chinese Journal of Anorectal Diseases, 2002, 22 (9): 11.

[2] Lu Houshan, Wang shirt. Colon and rectal surgery [M]. 4th edition. Beijing: People's Medical Publishing House, 2002, 188-201.