Anal Fissure

Definition:

• Ulcer or split in the skin lined (distal) part of the anal canal.
• Classical symptom is stab like / cutting glass pain on defecation
• Most fissure are acute and heal spontaneously.
• Common site is posterior midline (women-10% anterior)

Common Causes:

• Constipation-hard faecal bolus
• Childbirth(3-10%)
• Crohn’s disease -Management is medical- Immunosuppressives, Antibiotics, Little role for surgical treatment
• Occasional diarrheal especially in children
• Anal SCC
• Post-operative – haemorrhoidectomy

Chronic fissure;

• Thick indurated edges
• Sentinel tag
• Absence of granulation tissue with white fibres of Internal Anal Sphincter (IAS) visible at base.
• There is associated spasm of IAS causing pain and discomfort

Spasm of internal sphincter

• Leading cause of non-healing is spasm of the internal anal sphincter
• Poor blood supply and perfusion –posterior midline ischemia
• Treatment (both medical and surgical) is aimed at restoring the normal tone of the IAS

Treatment

• Medical /Non-operative treatment
  • Stool softeners
  • Sitz baths
  • Topical anaesthetics 2 % Lignocaine Jelly
  • Anti-inflammatory ointment
• Pharmaceutical Treatment
  • Topical Nitroglycerin GTN(nitric oxide) -Rectogesic 0.2% ointment
  • Topical calcium channel blockers
  • Oral calcium channel blockers
  • Botulinum toxin injections
• Surgical treatment
  • Lateral internal sphincterotomy (LIS) -(Currently Recommended Surgical Management)
  • Anal advancement flap (alternative to LIS)
  • Fissurectomy
  • Anal dilation (considered but not recommended
• Rectogesic ointment -GTN
  • Reducing intra-anal pressure (relax IAS)
  • Vasodilatory effect on anal vessels -Topical paste applied three time a day
  • 0.2% strength (compared with 2% strength for GTN patches)
  • >80% fissures healed in 2-3 weeks
  • Side effects include headaches, flushing and dizziness on standing, burning sensation in the anus, development of tolerance.
  • 25% of patients will be unable to tolerate
  • Calcium channel blockers (topical) is an alternative
  • 1- 2% Diltiazem cream-less S/E
• Botulinum toxin (Botox®) injection
  • Rapid action-within few hours
  • Non traumatic
  • Effect last 3-4 month –enough for fissure to heal
  • No damage /division of IAS
  • Very good option in females-already attenuated IAS





• Surgery-Lateral sphincterotomy;
  • 96% healing rate
    • Partial division of Internal sphincter
    • S/e-30 incontinence- Females at greater risk due to anatomically shorter anal sphincter and pre-existing childbirth injury.

    

  Advantages

  • Can be performed under LA as a day case
  • Wounds heal quickly
  • Low recurrence rates
  • Can perform concomitant procedure without increased risk of complication Ref; Leong, Dis Colon Rectum 1994; 37:1130-1132

  Disadvantages

  • Impaired continence - up to 38% notice some change
  • Soiling - 27% (open) vs 16% (closed); p< 0.001
  • Stool - 12% vs 3%; p< 0.001
  • Flatus - 30% vs 24%; p< 0.062

  Ref; Garcia-Aguilar, Dis Colon Rectum 1996; 440-443 (549 patients)

• Lords manoeuvre;
  • Forceful dilatation (8 fingers)of the sphincter complex is not practiced now days
• If fissure is not Non healing
  • Consider Crohn’s disease
  • HIV
  • Malignancy

Botox VERSUS Lateral internal Sphincterotomy (LIS)

• RCT, 111 patients
• 20-30 IU Botox(R) injected anteriorly (50) vs open LIS (61)

Mentes, Dis Colon Rectum 2003; 46:232-237