Anal Fissures

Anal fissure is a small laceration of the mucocutaneous junction of the anus. It is an acquired lesion secondary to the forceful passage of a hard stool.

Anal fissure may be suspected in children with constipation, extreme pain with defecation, rectal bleeding, or blood in the stool. There is no clear cause for anal fissure, but it can be associated with constipation, difficult bowel movements, and hypertonicity of the anal sphincter. This results in a vicious cycle of pain with bowel movements, and subsequent reluctance to have bowel movements and constipation.

Anal fissures can be painful but are also usually due to anal trauma from passing hard stool, though rarely they can be a harbinger of Crohn's disease. They heal slowly and are reinjured by the passage of subsequent hard stools. Relief of the constipation cures the condition in the vast majority of patients. Surgical treatment is almost never necessary. The presenting symptoms can be pain or bleeding, but perhaps the most common presenting complaint is a skin tag. For reasons that are unclear, fissures frequently cause adjacent perianal skin and subcutaneous tissue to become heaped up in such a way that a broad-based polypoid skin tag is the result. These are harmless and generally "cosmetic" concerns but parents are sometimes distressed by them. To make matters worse, they can persist for months or years (for life?) even after the fissure heals. They can be excised but parental reassurance is usually all that is necessary.

The diagnosis of anal fissure is made on clinical examination, with a linear disruption of the anoderm on visual inspection. Digital rectal examination is very painful if an anal fissure is present, but should be attempted if the diagnosis is not clear, to rule out other possibilities for anal pathology. If the diagnosis is clear on visual evaluation, omitting the digital examination is advisable.

The treatment for anal fissure should be aimed at interrupting the vicious cycle of painful bowel movements, subsequent reluctance to have bowel movements, and the resultant constipation. The goal of easy daily bowel movements will allow for gradual healing of the fissure. Initial therapy usually involves dietary changes including increasing fiber to add bulk to bowel movements and decrease straining with defecation. Soaking in the bathtub or sitz baths can provide some pain relief, and topical local anesthetic creams are sometimes also useful.

In the past, failure of initial medical management for anal fissures has resulted in surgical treatment such as internal anal sphincterotomy or anal dilations under anesthesia to relieve the hypertonicity of the anal sphincter and supposedly permit healing. These procedures are associated with a significant risk of incontinence. More recently in adults, nitroglycerin ointment has been used to reduce anal sphincter hypertonicity and is gradually replacing anal sphincterotomy as the preferred treatment for anal fissure. Prospective, blinded, placebo-controlled trials of treatment with 0,2% topical nitroglycerin ointment, local anesthetic cream, and placebo carried out in children have suggested that topical nitro-glycerin ointment results in faster complete healing of the anal fissure and resolution of symptoms. Regardless of the treatment chosen, it will likely take several weeks for symptoms to subside, and this must be shared with the family at the outset of treatment.

Дата добавления: 2014-10-15