LOWER GI HEMORRHAGE

FISSURE-IN-ANO

Dr.B.SELVARAJ MS;Mch;FICS:

PROFESSOR OF SURGERY

MELAKA MANIPAL MEDICAL COLLEGE

MELAKA 75150 MALAYSIA

FISSURE-IN-ANO

Causes of Lower GI Hemorrhage

Etiopathogenesis

Types of Fissre-In-Ano

Clinical features

Treatment

Mindmap

Diagnostic algorithm

Management Algorithm

Causes for Lower GI Hemorrhage

Diverticular disease

Angiodysplasia- AV Malformation

Colorectal carcinoma

Hemorrhoids

Fissure-in-ano

Ischemic colitis

Inflammatory bowel disease

Meckel’s diverticulum

Upper GI hemorrhage

CLASSICAL CLINICAL VIGNETTE

A 23 year old lady describes excruciating pain with defecation and blood streaks on the outside of the hard stools.

Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful.

Physical examination can not be done, as she refuses to allow anyone to even “spread her perianal area” to look at the anus for fear of precipitating the pain.

Diagnosis: Fissure-in-ano

EUA should be done to R/O other pathologies like Anal Carcinoma, Crohn’s disease, Tuberculosis, HIV and Leukemia

ETIOPATHOGENESIS

An anal fissure is an ulcer in the lower portion of the anal canal

Most tears of the anal canal are due to the passage of large, hard stool or explosive diarrhea, trauma to the anus, or a tear during vaginal delivery.

Patients have increased resting anal pressure caused by the increased tone of the internal sphincter muscle. This results in ischemia and ulceration to the overlying anal skin.

In men, almost all fissures are located in the posterior midline, whereas in women, 10% are in the anterior midline.

Types of Fissure-in-Ano

Acute Fissure-in-Ano: Symptoms

within one month

Chronic Fissure-in-Ano:

Symptoms 2 to 3 months duration

The primary fissure occurs

without association with other

local or systemic diseases

The secondary fissure occurs in

association with Crohn’s disease,

leukemia or aplastic anemia.

Clinical Features

Bleeding per rectum: Bleeding is painful associated with defecation.

It is bright red blood and blood usally streaks on the hard fecal

matter

Painful defecation: Anal pain during and after defecation is the most

prominent symptom.The pain is described as burning, throbbing, or

dull aching.

Physical examination confirms the diagnosis. Chronic fissures have

a triad of a fissure, sentinel skin tag, and hypertrophied anal papilla

In acute Fissure-in-Ano you shouldn’t do DRE or Proctoscopy for

fear of aggravating the pain.

TREATMENT

Nonoperative for all Acute and some chronic Fissure-in-Ano

a. Sitz bath—The patient is asked to sit in warm water with the anal

region and buttocks dipped in water for about 20 minutes,2 to 3 times

a day. This reduces pain, edema and promotes healing.

b. Antibiotics, laxatives (stool softener) and antiinflammatory drugs

are beneficial.

c. Regulation of bowel habit with a high fiber diet.

d. Local application of nitroglycerin or calcium channel blockers like

diltiazam lowers the resting anal sphincter tone.

e. Injection of Botulinium toxin lowers the resting internal sphincter

tone.

TREATMENT

Operative Treatment:

Anal fissures usually heals in six weeks. Surgery is not usually

required unless the conservative therapy fails.

Lateral internal Sphincterotomy is the surgical procedure of choice if

the anal sphincter tone is normal. This can be done as open or blind

subcutaneous lateral internal Sphincterotomy.

If anal sphincter tone is low- do endoanal v-y skin flap

Fissures or ulcers in Crohn’s disease are larger and deeper than

primary anal fissures. The surrounding skin is macerated and

edematous. Treatment consists of proper anal hygiene and treatment

of the underlying inflammatory disease.

TREATMENT

Notaras Closed blind subcutaneous lateral internal sphincterotomy

Open subcutaneous lateral internal sphincterotomy

MINDMAP

Diagnostic Algorithm

Treatment Algorithm

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