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ANAL FISSURA

DEFINITION

Anal fissure is a tear in the anoderm


distal to the dentate line. It can be
categorized as acute or
chronic.Acute fissures present with
anal pain, spasm, and/or bleeding
with defecation
EPIDEMIOLOGY

 The incidence of fissura anal is 1 in 350 people.


 The frequency of occurrence of fissure ani is similar between men
and women.
 Fissura ani is more likely to occur at a younger and middle age.
ETIOLOGY

• A Hemorrhoidal Condition
• Irritation Due To Diarrhea
• Partus Injury
• Crohn Disease
• Constipation
• Inflammatory Bowel Diseases
• Sexually Transmitted Diseases
• Anal Cancer
Symptoms

 Signs and symptoms of an anal fissure include:


 Pain, sometimes severe, during bowel movements
 Pain after bowel movements that can last up to several hours
 Bright red blood on the stool or toilet paper after a bowel movement
 Itching or irritation around the anus
 A visible crack in the skin around the anus
 A small lump or skin tag on the skin near the anal fissure
Pathophysiology

• Keighley Divides the ani fissures into:


1. Fissura ani primer
• Acute
• -Chronic
2. Fissura ani secondary.

Fissura ani primer tampak sbg suatu superficial ulcer pd


mukosa anal di bawah linea dentata, apabila letaknya lebih
ke proksimal hampir dpt dipastikan merupakan fissura ani
sekunder akibat penyakit lain.
If the hard stool passes through the anal canal

will be going stretching & tearing the anal mucosa.

Fissura usually occurs on the anterior & posterior

Allegedly this area is a weak area

when the stool passes through the anal canal, the mass
will be channeled to the anterior & posterior parts due to
the presence of muscles in the lateral part.
 In acute fissura ani → ulcers appear firmly bound,
there is no induration, odema or cavitation.
 In chronic fissura ani → visible edge of the ulcer
induration & if the process the ulcer continues to
expand and the outside looks odematous because
of lymphatic obstruction, skin tags & anal papilla
hypertropy can be found under the circumstances
fissura ani chronic.
DIAGNOSIS1
1. Anamnesis

 Pain in the rectal region, usually described as burning, feeling cut, or


torn like a feeling. The pain is in line with intestinal contractions; anal
spasm should be suspected of fissura ani.
 Constipation due to fear of pain.
 Feces hard
 Bleeding red bloody red on the surface of the stool. Blood usually
does not mix with feces.
 Mucoid discharge
 Pruritus
2. Physical examination

• Inspeksi
On inspection often found skin tags, fissures, and papilla hypertrophy
The examination is doing by slowly pulling both buttocks to see if there are
skin tags, discharges or blood.
• Palpation
The margins of fissura can be palpable irregular, tenderness (+). The direct
examination on fissura is very painful
• Proctoscopy / Sigmoidoscopy
The use of adult protoscop in acute circumstances is usually indispensable
probably done because of very pain. Usually using infant sigmoidoscopy
Llyod-Davies can be seen abnormalities in the rectal & anal mucosa canal.
3. supporting examination

blood count and


blood culture
Diferensial diagnosis

Crohn's Disease
Ulcerative Colitis
Tuberculous Anal Fissures
Syphlitic Fissures
Intersphincteric Abscess
Malignancy
Ani Pruritus
AIDS
Proctalgia Fugax
MANAGEMENT
 Advise the patient to increase dietary fibre and fluid intake to keep
bowel motions soft
 The importance of correct anal hygiene and the need to keep the anal
area dry should be emphasised.
 Regular sitz baths (sitting in warm water up to the hips) can help to relax
the sphincter.
 The patient should also be advised to avoid undue straining during
bowel movements.
 If lifestyle and dietary interventions are insufficient, or if the fissure is
severe, a stool softener, e.g. oral docusate sodium, and mild local
analgesia, e.g. lidocaine (not subsidised), may be prescribed.
 If the fissure fails to heal within three to six weeks, topical nitrates or
topical calcium channel blockers should be used. All topical
treatments for anal fissures should be applied for at least six weeks to
allow re-epithelialisation of the fissure
 If the fissure has not healed after six to eight weeks of topical treatment
and dietary changes secondary care to assess the appropriateness of
other treatments, usually botulinum toxin or surgery.
 Surgical techniques commonly used for anal fissures which aim to relax
the internal sphincter include; open lateral sphincterotomy, closed
lateral sphincterotomy and posterior midline sphincterotomy.

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