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Chapter 4

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Overview

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Anal fissures are frequent, simple to diagnose, and often overlooked. A fissure is a longitudinal tear/wound/ulceration between the dentate line and the anal verge, typically located in the midline, associated with high anal sphincter tone. Risk factors: constipation, chronic diarrhea (idiopathic, IBD, post–gastric bypass), but fissure may also occur with normal bowel movements.

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  • • Acute fissure is defined as new onset, no signs of chronicity, typically related to identifiable acute episode of constipation or diarrhea.
  • • Chronic fissure is defined as either > 3 months of symptoms or morphologic signs of chronicity (elevated/indurated wound edges, exposed sphincter muscle, sentinel skin tag, hypertrophic anal papilla).

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Complications are rare: development of a perirectal fistula/abscess, chronic pain (even if fissure healed), ie, anismus.

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Pathophysiology: acute or chronic stress/trauma to the anal canal (constipation, diarrhea) results in superficial tear; acute fissure will heal in 40–60% with appropriate improved stool management, or may turn into chronic anal fissure and result in a vicious circle: increasing sphincter tone, hypertonicity of internal anal sphincter muscle (resting tone) → fissure hiding between anal canal folding such that it cannot clean out → pain → increased sphincter spasm → etc.

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Treatment of fissure aims at normalizing stool regularity and decreasing sphincter tone.

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Epidemiology

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Exact prevalence and incidence are unknown (referral bias); in a specialist clinic, 3–5% of patients have a fissure as presenting symptom. More common in young and middle-aged adult patients; most frequent cause of rectal bleeding in children.

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Symptoms

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Patients often present with “painful hemorrhoids” as they feel the sentinel skin tag and notice the pain during and after bowel movements.

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Pain: typically post defecation, varying degrees, ranging from mild itching to discomfort to massive excruciating pain periods. But an estimated 10% of patients do not complain of pain, or they just have pruritus or mild discomfort.

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Duration of pain: typically during and post bowel movements, occasionally several hours thereafter, or permanent/constant pain.

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Bleeding: acute fissure—sometimes significant bright red bleeding; chronic fissure—more often just traces of blood on toilet paper. Severe hemorrhage or anemia unlikely related to fissure.

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Lump: “irritated” external hemorrhoids (sentinel skin tag), but absence of dynamic protrusion during bowel movement.

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Differential Diagnosis

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Pain: thrombosed external hemorrhoid, abscess, levator ani spasm, anismus.

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HIV-associated ulcer: HIV infection+; ulceration: often in the same location and/or eccentric; sphincter tone typically not increased, or even decreased.

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Crohn disease: anal symptoms may be the only manifestation or be associated with other signs/locations of active Crohn disease.

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STDs: syphilis, herpes.

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Perirectal fistula/abscess: particularly horseshoe fistula characteristically originates from posterior midline.

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Tuberculosis: clinical suspicion, atypical presentation, associated pulmonary symptoms, positive PPD test.

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