History

Fact Explanation
History of constipation or less commonly can be due to repeated diarrhoea Anal fissure is a longitudinal split in the squamous lining of the anal canal. It begins at the anal verge but does not extend beyond the dentate line. Commonly seen in posterior midline it caused by local trauma to the anal canal, by overstretching due to hard stools or repeated diarrhoea. [1]
Severe shooting type pain in perineal region It occurs during and following defecation lasting for minutes to hours, very painful as it involves the sensitive skin surrounding the anus.
Streaks of fresh blood on the stools Bright red blood (fresh blood) can be seen on the toilet paper sometimes. [1]
Males and females are equally affected Anterior fissures are less common and commonly seen among females. Occurs following vaginal delivery. Young adults are mostly affected, but patient at any age could be affected.
Systemic inquiry for features of Inflammatory Bowel Disease Sometimes (not commonly) a fissure may be associated with a systemic disease such as inflammatory bowel disease. Also to exclude the possibility of another diagnosis (e.g., anal carcinoma, sexually transmitted disease). In these cases,initially treat the underlying pathology .
Sexual history HIV and HPV can cause macroscopic anal lesions. it s important for the management. [2]
Itching, discharge from the perineal region When chronic, patients may complain of itching due to irritation from the sentinel tag, discharge from the ulcer or discharge from an associated intersphincteric fistula, when the fissure is complicated with infection. [3]
References
  1. RAKINIC JAN. Anal Fissure. Clinics in Colon and Rectal Surgery [online] 2007 May, 20(2):133-138 [viewed 09 August 2014] Available from: doi:10.1055/s-2007-977492
  2. ABRAMOWITZ L, BENABDERRAHMANE D, BARON G, WALKER F, YENI P, DUVAL X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum [online] 2009 Jun, 52(6):1130-6 [viewed 09 August 2014] Available from: doi:10.1007/DCR.0b013e3181a65f5f
  3. ZAGHIYAN KAREN, FLESHNER PHILLIP. Anal Fissure. Clinics in Colon and Rectal Surgery [online] December, 24(01):022-030 [viewed 09 August 2014] Available from: doi:10.1055/s-0031-1272820

Examination

Fact Explanation
Inspection Important step in the examination. Pain on parting the buttocks, sometimes presence of a sentinel tag are findings of underlying fissure, but examination under anaesthesia might be needed if failure for a thorough examination. Exclude other pathologies, such as squamous cell carcinoma of the anal canal. [1]
Digital examination of rectum adequately lubricated index finger is inserted and the soft tissues around the anus are palpated for induration, tenderness and subcutaneous lesions. Examine for any distal intrarectal, intra-anal or extraluminal mass.assess sphincter tone,there may be stenosis secondary to spasm or fibrosis of the internal sphincter. On withdrawing the finger look for the presence of mucus, blood or pus and to identify stool color.
Proctoscopy examination Inspection of the distal rectum and anal canal. Especially haemorrhoids can be examined. Look for other sinister pathologies like carcinoma.
Sigmoidoscopy This is an examination method of the rectum, it should be carried out even though an anal lesion was confirmed. As Rectal pathology such as colitis or carcinoma, is commonly associated with an anal lesions such as fissure or haemorrhoids. Not uncommonly, rectal pathology is found that is independent of the anal lesion and requires treatment.
References
  1. RAKINIC JAN. Anal Fissure. Clinics in Colon and Rectal Surgery [online] 2007 May, 20(2):133-138 [viewed 09 August 2014] Available from: doi:10.1055/s-2007-977492

Differential Diagnoses

Fact Explanation
Haemorrhoids Usually seen in elderly patients. Patients present with fresh bleeding. but usually no pain. There can be a history of constipation. Can be diagnosed by proctoscopic examination[1]
Malignant lesions in the anus and anal canal Most common symptoms are pain and bleeding and the disease is often falsely diagnosed as a benign condition. A mass, pruritus or discharge are less common symptoms. Advanced tumors may cause fecal incontinence by invasion of the sphincters.higher degree of suspicion is needed[3]
Inflammatory bowel disease: Crohn's disease These patients can be symptomatic or asymptomatic. Inflammatory bowel disease involving the anal region may lead to both fissure and fistula formation. Blood loss via stools and skin ulceration may be present[2]
Anal lesions caused by sexually transmitted diseases Sexually transmitted or human immunodeficiency virus (HIV)-related ulcers (syphilis,Chlamydia, chancroid, lymphogranuloma venereum, HSV, cytomegalovirus, Kaposi’s sarcoma, B-cell lymphoma)[4]
Tuberculosis fissure in ano Secondary to pulmonary tuberculosis. These patients have active TB in their body. Tuberculosis ulcerosa of the anus and anal fissure accompanied by pulmonary tuberculosis is rarely seen. However difficulty in patient identification makes diagnosis difficult. [6],[7]
References
  1. KONING MV, LOFFELD RJ. Rectal bleeding in patients with haemorrhoids. Coincidental findings in colon and rectum. Fam Pract [online] 2010 Jun, 27(3):260-2 [viewed 09 August 2014] Available from: doi:10.1093/fampra/cmq008
  2. ZAGHIYAN KAREN, FLESHNER PHILLIP. Anal Fissure. Clinics in Colon and Rectal Surgery [online] December, 24(01):022-030 [viewed 09 August 2014] Available from: doi:10.1055/s-0031-1272820
  3. VATRA B, SOBHANI I, APARICIO T, GIRARD PM, PUY MONTBRUN TD, HOUSSET M, BAILLET F, HECHT F, CHOSSIDOW D, SOULé JC. [Anal canal squamous-cell carcinomas in HIV positive patients: clinical features, treatments and prognosis]. Gastroenterol Clin Biol [online] 2002 Feb, 26(2):150-6 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/11938066
  4. ABRAMOWITZ L, BENABDERRAHMANE D, BARON G, WALKER F, YENI P, DUVAL X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum [online] 2009 Jun, 52(6):1130-6 [viewed 09 August 2014] Available from: doi:10.1007/DCR.0b013e3181a65f5f
  5. NALEPA P, PASOWICZ M, STRACZEK C. [Tuberculosis ulcerosa of the anus and anal fissure accompanied by pulmonary tuberculosis]. Pol Merkur Lekarski [online] 2006 Nov, 21(125):477-9 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/17345844
  6. MYERS SR. Tuberculous fissure-in ano. J R Soc Med [online] 1994 Jan, 87(1):46 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1294285

Investigations - for Diagnosis

Fact Explanation
It is mainly a clinical diagnosis Diagnosis is by clinical history and physical examination. However to exclude the other differential diagnosis patients have to undergo several investigations.
References

Investigations - Fitness for Management

Fact Explanation
Full blood count In preparation for surgery exclude anemia.
References

Investigations - Screening/Staging

Fact Explanation
Erythrocyte Sedimentation Rate These investigations are done if suspecting other underlying pathologies, eg:- crohn's disease, squamous cell carcinoma,tuberculosis.
Biopsy for histology Usually biopsies are not taken during surgery for anal fissures. If suspecting a malignancy or Crohn's disease a histology report can be taken
Virological studies for sexually transmitted diseases Perform a HIV screening if suspected.[1]
References
  1. ABRAMOWITZ L, BENABDERRAHMANE D, BARON G, WALKER F, YENI P, DUVAL X. Systematic evaluation and description of anal pathology in HIV-infected patients during the HAART era. Dis Colon Rectum [online] 2009 Jun, 52(6):1130-6 [viewed 09 August 2014] Available from: doi:10.1007/DCR.0b013e3181a65f5f

Management - General Measures

Fact Explanation
Sitz bath [5] Relieving of the pain and bleeding, as due to the pain the patient is afraid of defecation. This precipitates the constipation and this is a vicious cycle. This treatment has shown to decrease the pain and improve healing effectively no serious side effects. [1] Conservative treatment has a role in initial management[3]
Hydrocortisone ointment[4],[5] Shown to decrease the pain and improve healing effectively[1]
Lidocaine ointment[5] Causes decreasing pain but no additional effect in healing[1]
Adding adequate fiber and fluid to the diet [3],[5] For the management of constipation. It minimizes recurrence. [4]
Use of stool softeners such as docusate sodium or docusate calcium[5] Helps in management of pain and also improves healing[4],[5]
Local application of heat[4] To relax the hypertonic anal sphincter[2]
References
  1. JENSEN SL. Treatment of first episodes of acute anal fissure: prospective randomised study of lignocaine ointment versus hydrocortisone ointment or warm sitz baths plus bran. Br Med J (Clin Res Ed) [online] 1986 May 3, 292(6529):1167-1169 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1340178
  2. Lapid O, Walfisch S. Perianal and gluteal burns as a complication of hot water bottle treatment for anal fissure. Burns. 1999;25:559–560.
  3. SHUB HA, SALVATI EP, RUBIN RJ. Conservative treatment of anal fissure: an unselected, retrospective and continuous study. Dis Colon Rectum [online] 1978 Nov-Dec, 21(8):582-3 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/738173
  4. ZAGHIYAN KAREN, FLESHNER PHILLIP. Anal Fissure. Clinics in Colon and Rectal Surgery [online] December, 24(01):022-030 [viewed 09 August 2014] Available from: doi:10.1055/s-0031-1272820
  5. RAKINIC JAN. Anal Fissure. Clinics in Colon and Rectal Surgery [online] 2007 May, 20(2):133-138 [viewed 09 August 2014] Available from: doi:10.1055/s-2007-977492

Management - Specific Treatments

Fact Explanation
Surgical measures: Lateral internal sphincterotomy[1] Surgery is the management of choice,it relieves the ischaemia, and is a very effective method.[2,5] It is done under local, regional or general anaesthesia, and with the patient in the lithotomy or prone jack-knife position. Has a lower recurrence rate but faecal incontinence (96%) is the main complication. Side effects are predetermined by various factors such as age, parity,constipation and previous surgery. [3],[7]
Surgical measures: Anal dilatation This was a surgical method used in earlier days done under regional or general anaesthesia, now not in practice due to higher rates of fecal incontinence [11].
Surgical measures: Anal advancement flap A newer approach to minimize the continence following the standard treatment. [11]
Medical management By sphincter relaxation. Does not cause fecal incontinence[4] patient will require repeated evaluation of symptoms.
Topical nitroglycerine ointment It is a nitric oxide donor that acts by reducing spasm, pain is relieved, and increased vascular perfusion promotes healing. Should be applied four times per day to the anal margin. Effective treatment, but side effects such as headache and other NO related side effects can occur. [4],[6]
Topical calcium channel blockers: diltiazem, nifedipine Calcium channel blockers (CCBs) relax the internal anal sphincter by blocking the of calcium influx into the cytoplasm of smooth muscle cells. both nifedipine (0.2–0.5% gel) and diltiazem (2% cream) helps healing of fissure by decreasing anal sphincter. pressure.[8],[9]
Injection of botulinum toxin Botulinum is a toxin produced by Clostridium botulinum which acts as an inhibitory neurotransmitter preventing release of acetylcholine from the presynaptic endings. It relaxes of both the external and internal anal sphincters. [4],[8],[10]
References
  1. Bailey, R. V., R. J. Rubin, et al. (1978). "Lateral internal sphincterotomy." Diseases of the colon & rectum 21(8): 584-586.
  2. SCHOUTEN W. R., BRIEL J. W., AUWERDA J. J. A., DE GRAAF E. J. R.. Ischaemic nature of anal fissure. Br. J. Surg. [online] 1996 January, 83(1):63-65 [viewed 07 August 2014] Available from: doi:10.1002/bjs.1800830120
  3. Nyam, D. C. and J. H. Pemberton (1999). "Long-term results of lateral internal sphincterotomy for chronic anal fissure with particular reference to incidence of fecal incontinence." Diseases of the colon & rectum 42(10): 1306-1310.
  4. BRISINDA GIUSEPPE, MARIA GIORGIO, BENTIVOGLIO ANNA RITA, CASSETTA EMANUELE, GUI DANIELE, ALBANESE ALBERTO. A Comparison of Injections of Botulinum Toxin and Topical Nitroglycerin Ointment for the Treatment of Chronic Anal Fissure. N Engl J Med [online] 1999 July, 341(2):65-69 [viewed 07 August 2014] Available from: doi:10.1056/NEJM199907083410201
  5. Abcarian, H. (1980). "Surgical correction of chronic anal fissure: results of lateral internal sphincterotomy vs. fissurectomy—midline sphincterotomy." Diseases of the colon & rectum 23(1): 31-36.
  6. LUND JONATHAN N, SCHOLEFIELD JOHN H. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. The Lancet [online] 1997 January, 349(9044):11-14 [viewed 07 August 2014] Available from: doi:10.1016/S0140-6736(96)06090-4
  7. SHARP FR. Patient selection and treatment modalities for chronic anal fissure. Am J Surg [online] 1996 May, 171(5):512-5 [viewed 09 August 2014] Available from: doi:10.1016/S0002-9610(96)00017-7
  8. BHARDWAJ R, VAIZEY CJ, BOULOS PB, HOYLE CH. Neuromyogenic properties of the internal anal sphincter: therapeutic rationale for anal fissures. Gut [online] 2000 Jun, 46(6):861-8 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/10807901
  9. KATSINELOS P, PAPAZIOGAS B, KOUTELIDAKIS I, PAROUTOGLOU G, DIMIROPOULOS S, SOUPARIS A, ATMATZIDIS K. Topical 0.5% nifedipine vs. lateral internal sphincterotomy for the treatment of chronic anal fissure: long-term follow-up. Int J Colorectal Dis [online] 2006 Mar, 21(2):179-83 [viewed 09 August 2014] Available from: doi:10.1007/s00384-005-0766-x
  10. JOST WH. One hundred cases of anal fissure treated with botulin toxin: early and long-term results. Dis Colon Rectum [online] 1997 Sep, 40(9):1029-32 [viewed 09 August 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/9293930
  11. ZAGHIYAN KAREN, FLESHNER PHILLIP. Anal Fissure. Clinics in Colon and Rectal Surgery [online] December, 24(01):022-030 [viewed 09 August 2014] Available from: doi:10.1055/s-0031-1272820