Anal fissure

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Anal fissure
Classification and external resources
Anal fissure 2.jpg
An anal fissure
ICD-10 K60.0-K60.2
ICD-9 565.0
DiseasesDB 673
MedlinePlus 001130
eMedicine med/3532 ped/2938 emerg/495
MeSH D005401

An anal fissure or rectal fissure is a break or tear in the skin of the anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper, sometimes in the toilet. If acute they may cause pain after defecation[1] but with chronic fissures pain intensity is often less. Anal fissures usually extend from the anal opening and are usually located posteriorly in the midline, probably because of the relatively unsupported nature and poor perfusion of the anal wall in that location. Fissure depth may be superficial or sometimes down to the underlying sphincter muscle.

Causes[edit]

Most anal fissures are caused by stretching of the anal mucosa beyond its capability.

Superficial or shallow anal fissures look much like a paper cut, and may be hard to detect upon visual inspection, they will generally self-heal within a couple of weeks. However, some anal fissures become chronic and deep and will not heal. The most common cause of non-healing is spasming of the internal anal sphincter muscle which results in impaired blood supply to the anal mucosa. The result is a non-healing ulcer, which may become infected by fecal bacteria. In adults, fissures may be caused by constipation, the passing of large, hard stools, or by prolonged diarrhea. In older adults, anal fissures may be caused by decreased blood flow to the area. When fissures are found laterally, tuberculosis, occult abscesses, leukemic infiltrates, carcinoma, acquired immunodeficiency syndrome (AIDS) or inflammatory bowel disease should be considered as causes.[2] Some sexually transmitted infections can promote the breakdown of tissue resulting in a fissure. Examples of sexually transmitted infections that may affect the anorectal area are syphilis, herpes, chlamydia and human papilloma virus.[3]

Other common causes of anal fissures include:

Epidemiology[edit]

The incidence of anal fissures is around 1 in 350 adults.[6] They occur equally commonly in men and women and most often occur in adults aged 15 to 40.[6]

Prevention[edit]

For adults, the following may help prevent anal fissures:

  • Avoiding straining when defecating. This includes treating and preventing constipation by eating food rich in dietary fiber, drinking enough water, occasional use of a stool softener, and avoiding constipating agents.[7] Similarly, prompt treatment of diarrhea may reduce anal strain.
  • Careful anal hygiene after defecation, including using soft toilet paper and/or cleaning with water, plus the use of sanitary wipes.
  • In cases of pre-existing or suspected fissure, use of a lubricating ointment (It is important to note that hemorrhoid ointment is contraindicated because it constricts small blood vessels, thus causes a decrease in blood flow, which prevents healing.)

In infants, frequent diaper change can prevent anal fissure. As constipation can be a cause, making sure the infant is drinking enough fluids (i.e. breastmilk, proper ratios when mixing formulas). In infants, once an anal fissure has occurred, addressing underlying causes is usually enough to ensure healing occurs.

Treatment[edit]

Non-surgical treatments are recommended initially for acute and chronic anal fissures.[8][9] These include topical nitroglycerin or calcium channel blockers, or injection of botulinum toxin into the anal sphincter.[10]

Other measures include warm sitz baths, topical anesthetics, high-fiber diet and stool softeners.[11][12]

Medication[edit]

Local application of medication to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with nitroglycerine ointment,[13][14][15][16] and then calcium channel blockers in 1999 with nifedipine ointment,[17][18] and the following year with topical diltiazem.[19] Branded preparations are now available of topical nitroglycerine ointment (Rectogesic (Rectiv) as 0.2% in Australia and 0.4% in UK and US[20]), topical nifedipine 0.3% with lidocaine 1.5% ointment (Antrolin in Italy since April 2004) and diltiazem 2% (Anoheal in UK, although still in Phase III development). A common side effect drawback of nitroglycerine ointment is headache, caused by systemic absorption of the drug, which limits patient acceptability.

A combined surgical and pharmacological treatment, administered by colorectal surgeons, is direct injection of botulinum toxin (Botox) into the anal sphincter to relax it. This treatment was first investigated in 1993. However, in many cases involving Botox injections the patients eventually had to choose another cure as the injections proved less and less potent, spending thousands of dollars in the meantime for a partial cure. Lateral sphincterotomy is the Gold Standard for curing this affliction.[21] Combination of medical therapies may offer up to 98% cure rates.[22]

Surgery[edit]

Surgical procedures are generally reserved for people with anal fissure who have tried medical therapy for at least one to three months and have not healed. It is not the first option in treatment.

The main concern with surgery is the development of anal incontinence. Anal incontinence can include inability to control gas, mild fecal soiling, or loss of solid stool. Some degree of incontinence can occur in up to 45 percent of patients in the immediate surgical recovery period. However, incontinence is rarely permanent and is usually mild. The risk should be discussed with one's surgeon.

Surgical treatment, under general anaesthesia, was either anal stretch (Lord's operation) or lateral sphincterotomy where the internal anal sphincter muscle is incised. Both operations aim to decrease sphincter spasming and thereby restore normal blood supply to the anal mucosa. Surgical operations involve a general anaesthetic and can be painful postoperatively. Anal stretch is also associated with anal incontinence in a small proportion of cases and thus sphincterotomy is the operation of choice.

Lateral internal sphincterotomy[edit]

Lateral internal sphincterotomy (LIS) is the surgical procedure of choice for anal fissures due to its simplicity and its high success rate (~95%). In this procedure the internal anal sphincter is partially divided in order to reduce spasming and thus improve the blood supply to the perianal area. This improvement in the blood supply helps to heal the fissure, and the weakening of the sphincter is also believed to reduce the potential for recurrence. The procedure is generally performed as a day surgery after the patient is given general anesthesia. The pain from the sphincterotomy is usually mild and is often less than the pain of the fissure itself. Patients often return to normal activity within one week.

LIS does, however, have a number of potential side effects including problems with incision site healing and incontinence to flatus and faeces (some surveys of surgical results suggest incontinence rates of up to 36%).[23]

Though Lateral internal sphincterotomy (LIS) is considered safe on short term basis, there are concern about its long term safety. Pankaj Garg et al. recently published a systematic review and meta-analysis in which they analyzed the long term continence disturbance two years after the LIS procedure. They found the incidence of long term continence disturbance to be 14%. So caution and careful patient selection is needed before going in for LIS.[24]

Anal dilation[edit]

Anal dilation, or stretching of the anal canal (Lord's operation) has fallen out of favour in recent years, primarily due to the unacceptably high incidence of fecal incontinence.[citation needed] In addition, anal stretching can increase the rate of flatus incontinence.[25]

In the early 1990s, however, a repeatable method of anal dilation proved to be very effective and showed a very low incidence of side effects.[26] Since then, at least one other controlled, randomized study has shown there to be little difference in healing rates and complications between controlled anal dilation and LIS,[27] while another has again shown high success rates with anal dilation coupled with low incidence of side effects.[28]

See also[edit]

References[edit]

  1. ^ Gott, M. D.; Peter, H. (5 March 1998). "New Therapy Coming for Anal Fissures". The Fresno Bee (Fresno, CA: McClatchy Co). p. E2, "Life" section. 
  2. ^ "Common Anorectal Conditions". American Academy of Family Physicians. 
  3. ^ "Anal Fissure - Causes". NHS Choices. 
  4. ^ a b Collins, E. E.; Lund, J. N. (September 2007). "A Review of Chronic Anal Fissure Management". Techniques in Coloproctology 11 (3): 209–223. doi:10.1007/s10151-007-0355-9. PMID 17676270. 
  5. ^ http://my.clevelandclinic.org/disorders/anal_fissures/hic_anal_fissures.aspx
  6. ^ a b c "Anal Fissure - Basics - Epidemiology". Best Practice. British Medical Journal. Apr 23, 2012. Retrieved 30 June 2012. 
  7. ^ Basson, Marc D. (28 January 2010). "Constipation". eMedicine. New York, NY: WebMD. Retrieved 5 April 2010. 
  8. ^ Nelson RL, Thomas K, Morgan J, Jones A (2012). "Non surgical therapy for anal fissure". Cochrane Database of Systematic Reviews 2: CD003431. doi:10.1002/14651858.CD003431.pub3. PMID 22336789. 
  9. ^ Haq., Z.; Rahman, M.; Chowdhury, R.; Baten, M.; Khatun, M. (2005). "Chemical Sphincterotomy—First Line of Treatment for Chronic Anal Fissure". Mymensingh Medical Journal 14 (1): 88–90. PMID 15695964. 
  10. ^ Shao, WJ; Li, GC, Zhang, ZK (September 2009). "Systematic review and meta-analysis of randomized controlled trials comparing botulinum toxin injection with lateral internal sphincterotomy for chronic anal fissure". International journal of colorectal disease 24 (9): 995–1000. doi:10.1007/s00384-009-0683-5. PMID 19266207. 
  11. ^ "Anal Fissure - Treatment Overview". WebMD. Retrieved 27 September 2011. 
  12. ^ Poritz, Lisa Susan. "Anal Fissure Treatment & Management". Medscape. Retrieved 27 September 2011. 
  13. ^ =Loder, P.; Kamm, M.; Nicholls, R.; Phillips, R. (1994). "'Reversible Chemical Sphincterotomy' by Local Application of Glyceryl Trinitrate". British Journal of Surgery 81 (9): 1386–1389. doi:10.1002/bjs.1800810949. PMID 7953427. 
  14. ^ Watson, S.; Kamm, M.; Nicholls, R.; Phillips, R. (1996). "Topical Glyceryl Trinitrate in the Treatment of Chronic Anal Fissure". British Journal of Surgery 83 (6): 771–775. doi:10.1002/bjs.1800830614. PMID 8696736. 
  15. ^ Simpson, J.; Lund, J.; Thompson, R.; Kapila, L.; Scholefield, J. (2003). "The Use of Glyceryl Trinitrate (GTN) in the Treatment of Chronic Anal Fissure in Children". Medical Science Monitor 9 (10): PI123–126. PMID 14523338. 
  16. ^ Lund, J. N.; Scholefield, J.H. (4 January 1997). "A Randomised, Prospective, Double-blind, Placebo-controlled Trial of Glyceryl Trinitrate Ointment in Treatment of Anal Fissure". The Lancet 349 (9044): 11–14. doi:10.1016/S0140-6736(96)06090-4. PMID 8988115. 
  17. ^ Antropoli, C.; Perrotti, P.; Rubino, M.; Martino, A.; De Stefano, G.; Migliore, G.; Antropoli, M.; Piazza, P. (1999). "Nifedipine for Local Use in Conservative Treatment of Anal Fissures: Preliminary Results of a Multicenter Study". Diseases of the Colon and Rectum 42 (8): 1011–1015. doi:10.1007/BF02236693. PMID 10458123. 
  18. ^ Katsinelos, P.; Kountouras, J.; Paroutoglou, G.; Beltsis, A.; Chatzimavroudis, G.; Zavos, C.; Katsinelos, T.; Papaziogas, B. (2006). "Aggressive Treatment of Acute Anal Fissure with 0.5% Nifedipine Ointment Prevents Its Evolution to Chronicity". World Journal of Gastroenterology 12 (38): 6203–6206. PMID 17036396. Archived from the original on 12 May 2009. Retrieved 12 May 2009. 
  19. ^ Carapeti, E.; Kamm, M.; Phillips, R. (2000). "Topical Diltiazem and Bethanechol Decrease Anal Sphincter Pressure and Heal Anal Fissures without Side Effects". Diseases of the Colon and Rectum 43 (10): 1359–1362. doi:10.1007/BF02236630. PMID 11052511. 
  20. ^ "Rectiv". drugs.com. Retrieved 27 September 2011. 
  21. ^ Jost, W.; Schimrigk, K. (1993). "Use of Botulinum Toxin in Anal Fissure". Diseases of the Colon and Rectum 36 (10): 974. doi:10.1007/BF02050639. PMID 8404394. 
  22. ^ Tranqui, P.; Trottier, D.; Victor, C.; Freeman, J. (2006). "Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin". Canadian Journal of Surgery [Journal Canadien de Chirurgie] 49 (1): 41–45. PMC 3207506. PMID 16524142. Retrieved 2009-05-12. 
  23. ^ Wolff, B. G.; Fleshman, J.W.; Beck, D. E.; Church, J. M. (2007). The ASCRS Textbook of Colon and Rectal Surgery. Springer. p. 180. ISBN 978-0-387-24846-2. Retrieved 2009-07-15. [clarification needed]
  24. ^ Garg P, Garg M, Menon GR (March 2013). "Long-term continence disturbance after lateral internal sphincterotomy for chronic anal fissure: a systematic review and meta-analysis". Colorectal Dis 15 (3): e104–17. doi:10.1111/codi.12108. PMID 23320551. 
  25. ^ Sadovsky, R. (1 April 2003). "Diagnosis and management of patients with anal fissures - Tips from Other Journals" (Reprint). American Family Physician 67 (7): 1608. Archived from the original on 2008-02-09. Retrieved 2009-05-12. 
  26. ^ Sohn, M.; Weinstein, M. A. Anal Dilatation for Anal Fissures (PDF). Retrieved 2009-07-15. [dead link][dead link]
  27. ^ Yucel, T.; Gonullu, D.; Oncu, M.; Koksoy, F. N.; Ozkan, S. G.; Aycan, O. (June 2009). "Comparison of Controlled-intermittent Anal Dilatation and Lateral Internal Sphincterotomy in the Treatment of Chronic Anal Fissures: A Prospective, Randomized Study". International Journal of Surgery 7 (3): 228–231. doi:10.1016/j.ijsu.2009.03.006. PMID 19361582. 
  28. ^ Renzi, A.; Brusciano, L.; Pescatori, M.; Izzo, D.; Napolitano, V.; Rossetti, G.; del Genio, G.; del Genio, A. (January 2005). "Pneumatic Balloon Dilatation for Chronic Anal Fissure: A Prospective, Clinical, Endosonographic, and Manometric Study". Diseases of the Colon and Rectum 48 (1): 121–126. doi:10.1007/s10350-004-0780-z. PMID 15690668. 
  • Lund, J. N.; Nyström, P. O.; Coremans, G.; Herold, A.; Karaitianos, I.; Spyrou, M.; Schouten, W. R.; Sebastian, A. A.; Pescatori, M. (October 2006). "An evidence-based treatment algorithm for anal fissure". Techniques in Coloproctology 10 (3): 177–180. doi:10.1007/s10151-006-0276-z. PMID 16969620.