Anal Fissure: Finding the Root Cause Michael A. Jobst, MD, FACS, FASCRS Surgical Associates, PC -- Lincoln, NE 27 th Annual Management of Colon and Rectal Diseases February 23, 2019 Objectives Differentiate anal fissures from other sources of anorectal pain and bleeding Understand how trauma and spasm are the root cause of anal fissures Relax, and you will understand the basic premise that underscores fissure treatment Know when to refer to a surgeon and reassure them that we are here to help them relax their anal sphincters 1
Financial Disclosures Speaker/Proctor Intuitive Surgical, Inc. Speaker Pacira Pharmaceuticals, Inc. What s an anal fissure? I m sure I have hemorrhoids! Me: How can I help you today? Patient: I have terrible hemorrhoids! Me: Tell me about your symptoms. Patient: Well, Doc, it bleeds and it hurts whenever I have a BM. Me: Doesn t sound like hemorrhoids. You probably have an anal fissure. Patient: What s an anal fissure? I m sure I have hemorrhoids! Me: Let s take a look... 2
What is an anal fissure? Torn anoderm in the anal canal Cycles of pain and bleeding with bowel movements Exposed anal sphincter muscle becomes spastic Severe pain Restricted blood flow Poor healing 90% posterior midline; 8% anterior midline; 3% both Atypical location associated with Crohn s, leukemia, and STD s Sentinel tag (not a hemorrhoid!) Hypertrophied internal anal papilla (also not a hemorrhoid!) From Corman 6 th Ed. Who gets anal fissures? Any age, infant to elderly. Mean age 40 years. Equal gender distribution No racial/ethnic differences istockphoto.com 3
Fissure symptoms Pain Sharp pain during bowel movement Burning pain afterwards Achy pain for minutes to hours Bleeding Usually bright red Noted on toilet paper Streak on the stool Dripping into bowl Differential diagnosis Hemorrhoids Pruritis ani Condyloma accuminata Perianal abscess/fistula Anal cancer Sexually transmitted diseases Inflammatory bowel disease Tuberculosis Leukemia This Photo by Unknown Author is licensed under CC BY 4
What causes an anal fissure? Primary Etiologies Secondary Etiologies Constipation Diarrhea Vaginal delivery Anal sex Crohn s disease Anal cancer HIV, syphilis, chlamydia Leukemia Tuberculosis Sarcoidosis Diagnostic evaluation History Listen to the words Physical Examination Visualization Gently part the buttocks Carefully evert the anus Defer DRE and anoscopy until symptoms are under control 5
Location matters, but don t tell me the time! Recall: 90% posterior midline; 8% anterior midline Why don t anal fissures get better on their own? Most actually do get better without medical attention For fissures that do not spontaneously resolve: Pain leads to anal spasm Anal spasm results in higher anal resting pressure Anal perfusion is inversely related to anal pressure Poor perfusion prevents fissure healing A fissure that will not heal continues to hurt It s a vicious cycle! 6
TRAUMA Pain Sphincter spasm ELIMINATE SPASM Topical agents Acute fissure High anal canal pressure Botox Sphincterotomy Poor healing Local ischemia Reduced tissue perfusion IMPROVED PERFUSION & HEALING How to treat anal fissures: relaxation is key! Fiber and water intake Stool softeners Sitz baths Topical nitrates Topical calcium channel blockers Chemodenervation with Botox (OnabotulinumtoxinA) Partial Lateral Internal Sphincterotomy (PLIS) Anoderm advancement flap 7
Preparation J (and other magical concoctions) Nitroglycerine Rectiv 0.4% ointment twice daily (Rx) Nitroglycerine 0.2% ointment twice daily (compounded) Principal side effect is headache Calcium channel blockers Nifedipine 0.3% and Benzocaine 20% twice daily and reapply after BM Diltiazem 2% and Lidocaine 2% twice daily and reapply after BM Principal side effect is pruritis Either can be compounded in pure petroleum jelly if allergic to topical anesthetics Uh-oh, time to call the surgeon Atypical fissure Typical fissures that do not respond to medical management 8
Botox between the buttocks?!?! Clostridium botulinum exotoxin 1 st use for anal fissure 1993 Dose & technique varies 60-80% success; 40% recurrence Temporary incontinence: Flatus 18%; stool 5% Adjunctive maneuvers: Fissurectomy Post-injection nifedipine Sphincterotomy: still the gold standard 1839 Brodie; 1939 Miles Partially divide IAS Dentate line vs. tailored 94-98% success Lateral position reduces complications Incontinence 2-5% Staining vs frank incontinence Fissurectomy improves satisfaction but does not improve healing 9
When the sphincter is loose? Anal advancement flap Neither superior nor inferior to sphincterotomy Reasonable alternate to sphincterotomy No incontinence reported May be helpful in patients with preexisting fecal incontinence Anal fissure re-evaluation DRE and anoscopy Rule out anorectal neoplasm Flexible sigmoidoscopy vs. Colonoscopy Rule out more proximal source of bleeding Atypical fissure? CBC Colonoscopy CT abdomen and pelvis Examination under anesthesia This Photo by Unknown Author is licensed under CC BY-NC-ND 10
Anal fissure prevention Promote healthy bowel habits High fiber diet Adequate water intake Avoid straining during defecation Avoid diarrhea and constipation Work up diarrhea that lasts more than 6 weeks Refer to gastroenterology as needed Summary Trauma leads to pain and spasm Anal spasm prevents healing Vicious cycle ensues Botox Break the cycle Provide symptom relief Topical antispasmotics Botox Sphincterotomy Postdiagnostic evaluation DRE, anoscopy, endoscopy, CT, etc. Topical Nifedipine or Nitroglycerine Anal Sphincter Relaxation Sphincterotomy Prevention High fiber diet and more water 11
12