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CASE STUDIES OF |
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CASE PHOTOS |
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| Disease Conditions |
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Fissure-in-ano
| What is Fissure-in-ano?
A superficial tear/cut in the anoderm (specialized tissue that lines the anus and the anal canal) extending upwards from the anus is known as Fissureinano. The anoderm has no hair, sweat glands or sebaceous glands, but has abundance of sensory nerve ends which can sense slightest touch and pain. Thus the condition is very painful. |
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The condition constitutes about 8-17% of total number of patients seen by colonic and rectal surgeon. The disease affects equally both the sexes and all age groups, and is the commonest cause for rectal bleeding in infants. Anal fissures in children may indicate sexual abuse. |
Anal fissures are caused by trauma due to
- Passage of hard stool
- Chronic diarrhea
- Habitual use of cathartics
- Anal trauma (as in after a rectal examination using a speculum/digit or and can occur with anal intercourse)
- Anal fissures can be seen in patients with syphilis and other sexually transmitted diseases, tuberculosis, leukemia, inflammatory bowel disease such as Crohn disease, previous anal surgery, HIV, and other conditions or diseases.
- Incidence of anal fissures in patients with leukemia is approximately 24%.
- Start by optimizing patient placement; place patient in left lateral decubitus position with knees drawn up toward chest.
- Examine patient carefully to avoid infliction of further pain or sphincter spasm. Examination may be facilitated by application of a topical anesthetic, such as Lidocaine jelly, prior to digital rectal examination.
- Most fissures are visible externally when patient bears down as if having a bowel movement.
- Note depth of fissure and its orientation to the midline, often described using clock orientation of hour hand.
- Majority of tears are found in the posterior midline.
- Rectal examination is generally difficult to tolerate because of sphincter spasm and pain.
- Acute fissures are erythematous and bleed easily.
- With chronic fissures, classic fissure triad may be seen.
- Deep ulcer
Sentinel pile, which forms when base of fissure becomes edematous and hypertrophic (a resolving sentinel pile can result in a permanent skin tag or may become associated with a fistulous tract).
Enlarged anal papillae
Bidigital rectal examination in a patient with a fistula-in-ano may reveal an indurated tract or cord.
- Fistula can be identified by small circles of granulation tissue, which exude pus when compressed if tissue is patent.
- A fistulous tract that opens internally can be visualized with aid of an anoscope.
- Inguinal lymph nodes may be enlarged and painful.
- In an acute fistulous abscess, cardinal signs of inflammation, rubor, dolor, calor, and tumor (eg, erythema, pain, increased temperature, edema) may be found.
- Examination of anus reveals a linear tear in fissure-in-ano.
- Stress importance of diet modification to soften stools.
- Patients should increase fruits, vegetables, and soluble and insoluble fibers in their diets and increase fluid intake.
- Acute fissures can become chronic.
- Sentinel pile can result.
- Permanent skin tag can result.
- Fistulas may form.
The following surgical complications may occur:
- Urinary retention
- Bleeding
- Abscess formation
- Flatus and liquid incontinence
| Recurrence of fissures | Top |
- Without treatment, chronically infected fistulas may cause systemic illness.
- Carcinoma has been reported in chronic untreated anorectal fistulas.
- Most uncomplicated fissures resolve in 2-4 weeks with supportive care.
- Chronic anal fissures frequently require surgical treatment.
- Prognosis for fistulas is excellent after surgery.
- Diet modification in the case of anal fissures
- For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles, Anal Abscess, Rectal Pain, and Rectal Bleeding.
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