Download Anal Fissure and Fistula

Anal Fissure and Fistula
By Mike Parenteau
Anal Fissure
 an unnatural crack or tear in the anus,
usually extending from the anal opening
and located posteriorly in the midline.
This location is probably because of the
relatively unsupported nature of the rectal
wall in that location.
Etioloogy / Pathophysiology
 Most anal fissures are caused by
stretching of the anal mucosa beyond its
capability. Various causes of this fissure
include:
 Straining to defecate, especially if the
stool is hard and dry
 Severe and chronic constipation
 Severe and chronic diarrhea
Etioloogy / Pathophysiology
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Crohn's disease and Ulcerative colitis
Anal sex or dildo use
Anal stretching
Insertion of foreign objects into the anus
Tight sphincter muscles
Excessive anal probing
Clinical Mainfestations
 The symptoms of anal fissure include:
 Pain during, and even hours after,
defecation
 Visible tear in the anus
 Blood on the stool or on toilet paper or
toilet bowl
 Constipation
 Burning, possibly painful, itch
Medical Management
 Most anal fissures are shallow or superficial
(less than a quarter of inch or 0.64 cm deep).
These fissures self-heal within a couple of
weeks. While waiting for the fissure to heal,
topical or suppository containing antiinflammatory agents and local anesthetic can
be used. Furthermore, treatment used for
hemorrhoid such as eating a high-fiber diet,
using stool softener, taking pain killer and
having a sitting bath
Medical Management
 Painful deep fissures, on the other hand
cut through the sphincter muscle thus
making it prone to spasm, which
exacerbates the fissure and aborts the
healing process. Medications such as
nitroglycerine and nifedipine ointments
can relax the sphincter muscle
Medical Management
 Surgical intervention may be required for
persisting deep anal fissures unresponsive to
the above conservative measures. Procedures
include:
 Internal lateral sphincterotomy or excising a
portion of the sphincter
 Anal dilation or stretching of the anal canal is
no longer recommended because of the
unacceptably high incidence of fecal
incontinence
Anal Fistula
 Abnormal opening on the cutaneous
surface near the anus.
 Abnormal connection between the
epithelialised surface of the anal canal
and (usually) the perianal skin
 Usually this is from a local crypt abscess
and also is common in Crohns.
Symptoms
 Anal fistulae can present with many
different symptoms:
 Pain
 Discharge - either bloody or purulent
 Pruritus ani - itching
 Systemic symptoms if abscess becomes
infected
Objective
 The opening of the fistula onto the skin
may be seen
 The area may be painful on examination
 There may be redness
 An area of induration may be felt thickening due to chronic infection
 A discharge may be seen
Medical Management
 Doing nothing - a drainage seton can be left in place
long-term to prevent problems. This is the safest option
although it does not definitively cure the fistula.
 Conversion to a cutting seton - this involves a similar
process to a draining seton but the suture is tied tightly.
This gradually cuts through the muscle and skin
involved, leaving behind a small area of scarring. This
cures the fistula in most cases, but can cause
incontinence in a small number of cases, mainly of
flatus (wind).
Medical Management
 involves an operation to cut the fistula open and let it
heal naturally. This cures the fistula but leaves behind
a scar, and can cause problems with incontinence. This
option is not suitable for complex fistulae, or those that
cross the entire anal sphincter.
 Fibrin glue injection is a method explored in recent
years, with variable success. It involves injecting the
fistula with a biodegradable glue which should, in
theory, close the fistula from the inside out, and let it
heal naturally. This method is perhaps best tried before
all others since, if successful, it avoids the risk of
incontinence, and creates minimal stress for the
patient.
Medical Management
 Fistula plug is an "advanced" version of the
fibrin glue method. It involves "plugging" the
fistula with a "plug" made of porcine small
intestine submucosa (sterile, biodegradable),
fixing the plug from the inside of the anus with
suture, and, again, letting the fistula heal
"naturally" from the inside out. According to
some sources, the success rate with this
method is as high as 80%.
Medical Management
 Endorectal advancement flap is a procedure in which
the internal opening of the fistula is identified and a flap
of mucosal tissue is cut around the opening. The flap is
lifted to expose the fistula, which is then cleaned and
the internal opening is sewn shut. After cutting the end
of the flap on which the internal opening was, the flap
is pulled down over the sewn internal opening and
sutured in place. The external opening is cleaned and
sutured. Success rates are variable and high
recurrence rates are directly related to previous
attempts to correct the fistula.
Plug