FISSURE IN ANO DR. RAJ AWASTHI - PowerPoint Presentation

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FISSURE IN ANO

DR. RAJ AWASTHI

Assistant professor

Department of Surgery

CIMS&H, Lucknow

Definition

: It is a common disease of anus and a painful condition which makes the patient often anxious and embarrassed. The word ‘Fissure’ means crack. It is longitudinal crack in the long axis of the lower anal canal. In other words we can just say that it is true ulcer of the anoderm below the dentate line of the anal canal.

FISSURE IN ANO

Anatomy of the rectum & anal canal

External

Internal

Anoderm

Swell, discomfort, difficult hygiene

Pain?

-> Thrombosed

Pain?

-> painless

Bright red bleeding

Prolapse associated with defecation

Anorectal Anatomy

Anal verge

Anal canal

Arterial Supply

Inferior rectal A middle rectal A

Venous drainage

Inferior rectal V middle rectal V

3

hemorrhoidal

complexes

L lateral

R

antero

-lateral

R posterolateral

Lymphatic drainage

Above dentate: Inf. Mesenteric

Below dentate: internal iliac

Nerve Supply

Sympathetic: Superior hypogastric plexus

Parasympathetic:

S234 (

nerviergentis

Pudendal Nerve:

Motor and sensory

AETIOLOGY

Poor muscular support of the posterior wall of the anal canalAcute angulations of the posterior rectal wall with the posterior wall of the anal canalTrauma – when a scybalous mass of stool is being expelledAnal infection – any infection within the anal canal( like followed by diarrhea etc. or due to poor hygienic conditions) is followed by inflammation which may turn into ulcerConstipation – a forceful defecation due to hard stool can cause over stretching of the anal mucosa resulting in ulcer

Predisposing Factors

Chronic constipationHard Stool (scybela)Prolong diarrhoea and dehydrationAnal sexSecondary to other diseaseAs a complication of some Medicines like NSAID steroids

Pain at anal region while & after defecation, which subsequently continues as a burning discomfort for several hours.

Sharp, cutting or tearing pain with act of defecation Severity of pain frightens the patient to defecateSlight bleeding- usually stools are streaked with the blood Swelling and Pruritis – Patient with a large sentinel tag may complain of painful external swelling with or without PruritisAge and Sex – More common in women & occurs during young & middle ages. It is uncommon in aged because of musculature atone.Location – Overall 90 % situated at midline posterior i.e. at 6 o’ clock. Anterior fissure ( 12 O’ clock ) is common in females, whereas commonest site in male is 6 O’ clock. In one percent of cases it is found in both anterior and posterior positions.CLINICAL FEATURES

Why Pain is more in Fissure ?Pain is more because during defecation, the anal fissure is stretched & the margins of the anal ulcer are separated.The anal skin has somatic sensory nerve supply which is very sensitive & causes sphincter spasm, leading to painful contraction. Here, one thing should be made clear that Spasm of the sphincter muscles results in pain, whereas the fatigue results in relief from pain. The attention of the patient is usually centered in his pain to the extent that he fails to mention the bleeding.

Two types of Fissure are seen –

1. Acute Fissure: - Sharp, cutting or tearing pain with act of daefication - It is deep tear through the skin of the anal margin extending into the anal canal. - There is little inflammatory induration or edema of its edges. - There is accompanying spam of the anal sphincter muscle2.Chronic Fissure: - It is comparatively less painful condition - Inflamed induarated margin may be present. - A base consisting of either scar tissue or the lower border of the internal sphincter - the ulcer is cone shaped with skin tag i.e sentinel pile. - Infiltration of fibrosed tissue in the bed of ulcer. - Infection is common causing proctitis, abscess or cutaneous fistula.

TYPES OF FISSURE

Fissure can be further divided into two types :

Primary : Already discussed Secondary: May be due to Granulomatous infection Chrons disease Syphilis Proctocoliitis Diabetes Mellitus As a compilation of Haemorriodectomy or fistulomtomy

If fissure is not treated it can cause - Abscess or fistula - Sentinel tag - Enlarged Papillae - Anal contractures Differential diagnosis - Anal abrasion - Specific ulcerative lesion - Venereal lesion - Tubercolosis - Carcinoma of anus - Proctalgia Fugax( Cramp like pain at irregular intervals more common with anxiety patient) -Chron’s disease

Medical treatment

Sitz bathLocal application of hot packs Application of Anesthetic ointments LaxativesBulking agents like isapgol husk To avoid constipation regularize bowel habit Injection of long acting local anesthetics Treatment

Surgical Treatment

1. Anal dilatation : Stretching of anal sphincters to achieve fatigue of anal sphincters and to break the fibrosed tissue embedded in ulcerLimitationsWith in few hours of stretching patient develops painful edemaSome patients may develops temporary incontinence In 16% patients this treatment is not successful

2.

Excision of Anal fissure with or without grafting -Excision of broad triangle of skin of perianal region along with the main lesion is done.

3. Sphintereotomy : Division of internal sphincter is done by either, - Open posterior internal sphincterotomy or - Lateral subcutaneous internal sphincterotomy at 3 o’clock position.

Complication

Anal incontinence ( temporary or permanent impaired control of feces is observed in 34% patients )Incontinence of flatus ( Observed in 9% of patients) Local hematoma formation.

Thank you