Anal Fissure- A Real Pain In The…

Conflict of Interest Declaration: Nothing to Disclose

Presenter: Harshad Telang

Title of Presentation: Anal Fissure- A Real Pain In The …

I have no financial or personal relationships to disclose

Rectal Pain

• Character of pain

• Intensity

• Duration

• Constant or intermittent

• Associated symptoms- ie bleeding, constipation

Rectal Pain

• Physical Examination

• Presence of mass

• Deep tissue bulging

• Tight sphincter

• Severe pain with rectal exam

Anal Fissure

• Small linear tear in anal mucosa

• Majority occur in posterior midline

• In women 10% found in anterior midline; less than 1% in males

Diagnosis

• History alone usually renders dx. w/ symptoms of tearing, knife-like pain w/ or w/o bleeding, usually associated with forceful hard stool or diarrhea.

• Pain starting w/ defecation lasts minutes to hours

• Fear of symptoms often causes pt. to withhold stooling, exacerbating constipation, impaction and pain.

Examination

• Gentle retraction of buttocks; pain is noted as fissure is exposed.

• Edematous sentinel tag may be present

• White fibers of internal sphincter may be seen in base of fissure or may be covered by thin epithelium which may hide the fissure

• Digital exam may be attempted with very well lubricated finger pushing away from fissure.

• Overhanging edges suggest chronicity

Etiology

• The initiating factor is trauma, typically overstretching of the anoderm by a large hard stool

• Linear tear along the longitudinal axis of overlying epithelium covering internal sphincter.

• Higher resting internal sphincter pressures are found in people with fissures

• Possible decrease in blood flow as cause of fissures, accounting for the pain

• Because increased resting anal pressure is associated with decreased mucosal blood flow- two may be related

Non-Operative Treatment

• Warm baths and a diet sufficiently high in fibre to achieve soft bulky stools allows approximately 50% of acute anal fissures to heal within three weeks.

• Stool softeners and fibre supplements are reasonable additions

• Recurrence is common, in the range of 30 - 70%, but can be reduced to 15 - 20% by maintaining a high fibre diet

Non-Operative Treatment- Acute Fissure

• Nitric oxide has been identified as the chemical messenger of the intrinsic non-adrenergic, non-cholinergic pathway mediating relaxation of the internal anal sphincter.

• Topical application of nitroglycerin, a nitric oxide donor, causes a transient lowering of resting anal pressure and an increase in anodermal blood flow.

• A 92% healing rate within two weeks for acute fissures treated with application of 0.2% glyceryl trinitrate ointment t.i.d.

Non-Operative Treatment

• Hydrocortisone creams and local anesthetic ointments such as lidocaine may help

• Topical nitroglycerin ointment ranging fr. 0.15% to 0.8% three to four times a day; concentration greater than 0.2% required to decrease MRAP by 25% but headaches increase accordingly

• Diltiazem used as means of “chemical sphincterotomy”. Best used as 2% topical preparation. Side effects generally less frequent vs. nitroglycerin

Non-Operative Treatment- Acute Fissure

• Topical calcium channel blockers (2% diltiazem, 0.3% nifedipine) .

• Heal 65-95% of fissures .

• The most common side effects are

headache, flushing, and symptomatic

hypotension.

Non-Operative Treatment- Chronic Fissure

• Topical Nitroglycerin: At eight weeks healing was observed in 68% of the GTN

• Botulinum Toxin: Botulinum toxin has been injected into the external and internal sphincters and, with short term follow up, healing rates of 80% have been achieved. Botulinum toxin injected into external anal sphincter on both sides of fissure

Operative Treatment

• Most sphincterotomies done as outpatient procedures with sedation and IV anesthesia.

• Intersphincteric groove palpated laterally. Incision made in the groove with division of internal anal sphincter

• the open technique involves making an incision across the intersphincteric groove, separating the internal sphincter from the anal mucosa by blunt dissection, and dividing the internal sphincter using scissors.

• the closed technique or subcutaneous technique involves making a small incision at the intersphincteric groove, inserting a scalpelwith the blade parallel to the internal sphincter and advancing it along the intersphincteric groove, and then rotating the scalpel towards the internal sphincter and dividing it.

Complications of Sphincterotomy

• Minor fecal incontinence and difficulty controlling flatulence are common side effects following surgery. Persistent minor fecal incontinence has been reported in 1.2% to 3.5% of patients; however, this does not appear to be significantly different to the rate of minor fecal incontinence experienced by patients treated with topical GTN.

• Hemmorhage can occur, more often with the open technique, and may require suture ligation.

• Perianal absess occurs in about 1% of closed sphincterotomies, generally in association with anal fistula caused by a breach of the anal mucosa by the scalpel. Incision and drainage of the abscess and fistulotomy are required

Fistula-in-ano and Perianal Abscesses

• Can be considered on a continuum

• Abscess can lead to fistula

• The cryptoglandular hypothesis states that infection of the anal glands associated with the anal crypts is the primary cause of perianal abscesses

• Perianal abscesses can then progress to fistula- an abnormal connection between two epithelialized surfaces, the anorectal mucosa and the skin

Other causes of fistula

Crohn’s

TB

Actinomycosis

Carcinoma

Trauma

Radiation

Foreign body

Lymphoma

Pelvic inflammation

Leukemia

Treatment

• Incision and drainage

• Packing not necessary for longer than a couple of days

• Antibiotics not necessary unless immunocompromised or systemic manifestations

• After I&D may develop into fistula- no way to predict or avoid

• Risk of abscess becoming fistula 26- 38%

Goodsall’s Rule

Park’s Classification of Fistula-in-ano

Imaging Studies

• Fistulogram

• Endoanal ultrasound

• CT

• MRI

Management

• No good nonsurgical management except for Crohn’s fistulae- infliximab

• Operative management- fistulotomy, Seton suture, mucosal advancement flap, fistula plug, ligation of intersphincteric fistula tract (LIFT procedure)

Fistulotomy

Seton Suture

Fistula Plug

Mucosal Advancement Flap

Prognosis

• Standard fistulotomy - The reported rate of recurrence is 0-18%, and the rate of any stool incontinence is 3-7%.

• Seton use - The reported rate of recurrence is 0-17%, and the rate of any incontinence of stool is 0-17%.

• Mucosal advancement flap - The reported rate of recurrence is 1-17%, and the rate of any incontinence of stool is 6-8%

Hemorrhoids

• represent engorgement or enlargement of the normal fibrovascular cushions lining the anal canal.

• chronic straining secondary to constipation or occasionally diarrhea

• fibrovascular cushions lose their attachment to the underlying rectal wall.

Hemorrhoids

• right anterior, right posterior and left lateral positions

• those originating above the dentate line which are termed internal

• those originating below the dentate line which are termed external.

Classification

• Grade I - bleeding without prolapse.

• Grade II - prolapse with spontaneous reduction.

• Grade III - prolapse with manual reduction.

• Grade IV - incarcerated, irreducible prolapse.

Evaluation

• rule out rectal cancer.

• young individual with bleeding associated with hemorrhoidal disease and no other systemic symptoms, and no family history, perhaps anoscopy and rigid sigmoidoscopy

• older individual, with either a family history of colorectal cancer, or change in bowel habits, a complete colonoscopy should be performed to rule out proximal neoplasia.

Treatment

• varies from simple reassurance to operative hemorrhoidectomy.

• Treatments are classified into three categories:

1) Dietary and lifestyle modification.

2) Non operative/office procedures.

3) Operative hemorrhoidectomy.

Rubber Band Ligation

• Grade I or Grade II hemorrhoids and, in some circumstances, Grade III hemorrhoids.

• Complications include bleeding, pain, thrombosis and life threatening perineal sepsis.

• successful in two thirds to three quarters of all individuals with first and second degree hemorrhoids.

Infrared Coagulation

• generates infrared radiation which coagulates tissue protein and evaporates water from cells.

• is most beneficial in Grade I and small Grade II hemorrhoids.

Electrocoagulation

• It works, in theory, similar to photocoagulation or to rubber banding.

• the probe must be left in place for ten minutes.

• poor patient tolerance minimized the effect of this procedure.

• Sclerotherapy

• Cryotherapy

Surgical Hemorrhoidectomy

• The triangular shaped hemorrhoid is excised down to the underlying sphincter muscle.

• Wound can be closed or left open

• stapled hemorrhoidectomy has been developed as an alternative to standard hemorrhoidectomy

Levator Ani Syndrome

• Pain, pressure and ache in anorectal area

• Occurs sporadically

• Lasts up to an hour

• Can be fairly severe

• Proctalgia Fugax variant- occurs mainly at night and ususally severe pain

Levator Ani Syndrome

• Spasms of levator ani, and particularily pubococcygeus

• Etiology unknown

•

Pelvic Floor

Levator Ani Syndrome Treatment

• No good treatment available

• Massage of perineum and warm baths

• Biofeedback- relaxation training

• Electrogalvanic stimulation