© Borgis - New Medicine 1/2005, s. 2-4
Łukasz Ulatowski, Grzegorz Krasowski
Anal fissure
Departament of Surgery, Wolski Hospital,Warsaw, Poland
Head: Marek Kruk MD, PhD
Summary
Anal fissure is a benign condition of the anus, most commonly found in the posterior commissure, causing severe rectal pain and bleeding. In the present paper the authors review the available literature and describe the pathogenesis, manifestations as well as currently employed treatment methods with respect to the division into acute and chronic anal fissures.
INTRODUCTION
Anal fissure is one of the most frequent benign conditions of the anus. Due to its symptoms related to defecation (severe pain, bleeding, pruritus), the fact that it tends to become chronic and troublesome for the patient, as well as a long-term and difficult treatment, the condition still raises a vital concern in modern proctology. The term anal fissure refers to a longitudinal tear in the mucosa of the anoderm and the anal canal, extending from the external anal orifice to the pectinate line. Anal fissure is frequent in young active professional adults; its peak incidence is in the third and fourth decades of life. The general prevalence rate in men and women is similar, however, more men than women are affected in the group under the age of 20 years; in women, the condition is more common at a later age. Anal fissure may also occur in infants; some authors have reported the condition in about 80% of one-year old infants, which, with adequate hygiene, heals spontaneously. Anal fissure does not only produce symptoms, but it may also be an aetiological factor in chronic constipation.
PATHOPHYSIOLOGY
The current approach shows that the condition is caused by an impaired anorectal motor function manifested by, e.g., an exaggerated resting sphincter spasm, a paradoxical sphincter spasm on defecation. This assumption has been confirmed by manometry which shows an increased pressure in the anal canal up to 120mm Hg (reference value approx. 70 mmHg). The abnormality results in an inadequate blood supply to the distal portion of the anal canal with resulting tissue anaemia and susceptibility to trauma. This has been confirmed by an increased blood flow in the anal mucosa after an effective treatment [1]. The theory presented by Gibbons and Read assumes that the fissure formation is mainly due to an impaired motor function of the sphincters. An inflammatory aspect is also worth considering – it accounts for an increased prevalence of anal fissure in patients with persistent diarrhoea. During degradation, perianal and cryptal faecal residue releases irritant substances, which leads to inflammation.
SYMPTOMS AND SIGNS
Severe colicky pain on defaecation, which may persist after the passage of stool, is the main symptom in anal fissure. The pain is due to a strong involuntary spasm of the internal anal sphincter. This may be subsequently followed by difficult defaecation and bleeding from the anus. Mucous and faecal discharge may appear in the course of the disease. The patient experiences a ”wet anus”; occasionally, pruritus may develop. In view of their duration and severity of symptoms, anal fissures are divided into acute and chronic. Diagnosis is not difficult: inspection of the anus reveals a linear tear in the anal mucosa which is most frequently found (75%) at the posterior commissure, in the midline. Anterior anal fissures occur more frequently in women; concomitant posterior and anterior anal fissures are rare. Chronic anal fissures have a typical appearance: a hypertrophied papilla in the dentate line (a sentinel pile) at the lower end, and pale fibres of the internal sphincter, a hypertrophied marginal fold, known as Brodie´s pile, at the upper end. A chronic, painless anal fissure in a lateral location, makes it imperative for the clinician to search for an underlying pathology, e.g., Crohn´s disease or AIDS. In some cases fissure-like lesions are accompanied by a macerated anal verge. Since it is painful, rectal examination and instrumental diagnostic procedures are contraindicated in patients with anal fissure. A thorough proctological examination is performed when the acute stage of the disease has subsided.
TREATMENT
Treatment methods in anal fissure have changed with a changing approach to the aetiology of the condition. All the current methods include multidirectional activities reducing the internal anal sphincter spasm and restoring normal anorectal reflexes. Anti-inflammatory and analgesic treatment is also crucial – it decreases the sphincter spasm involuntarily. At present, the general belief is that the treatment should be started with conservative methods which are effective in 50% of cases, particularly in acute anal fissure. The diet should consist of high-residue, high-fibre content to increase the stool bulk and to dilate the anal canal. An adequate diet plays a key role in the treatment as it decreases the recurrence rate. The conservative treatment also includes a warm sitz-bath diminishing the sphincter spasm, topical stool softeners, anti-inflammatory drugs and analgesics (metronidazole, non-steroidal anti-inflammatory drugs (NSAIDs), steroids). Pharmacological agents reducing the sphincter tone are commonly used. These are calcium-channel blockers, topical botulinum toxin and nitroglycerin ointment. The most frequently administered calcium channel blocker is diltiazem given orally at a dose of 20mg three times daily; it reduces the sphincter pressure by 20mmH20 and acts for 3 to 5 hours following administration. The agent may also be applied topically as an ointment, but in 10% of patients it causes perianal pruritus [2]. Some reports show the efficacy of lacidipine at a dose of 6 mg daily; it does not produce significant changes in arterial blood pressure and is well tolerated by patients [3]. The preparations may also be used topically (e.g., nifedipine). The healing rate of anal fissure accounts for 95% [4]. Injection of botulinum toxin to the sphincter area has also been practised and recommended by some authors as the treatment of choice [5]. The toxin produces a transient decrease in the sphincter tension for a three-month period. The therapy has been found to be safe (with a low percentage of complications) [6] and effective in 90% of cases of chronic anal fissure [8]. Some authors recommend administration of two 25 IU doses of botulinum toxin [9]; contraindications include anal fissures with severe scarring as well as concomitant abscesses or anal fistulas [10].
The treatment of anal fissures also consists of nitroglycerin ointment which acts locally by its metabolite, i.e. nitric oxide, reducing the smooth muscle tension. The drug is applied as 0.2-0.5% ointment twice daily. Healing rate accounts for 70% of cases [11]. Unfortunately, treatment with nitrates is not free from side effects including headaches, which frequently leads to discontinuation of the therapy. The recurrence rate is also high and amounts to 33% [12].
Reports have been published in literature on an effective topical treatment with ointment containing L-arginine; there are no headaches and the sphincter tone is effectively reduced by 46% [13].
Indications for surgical operation include a failed conservative therapy, denuded internal sphincter fibres, the presence of a large-size sentinel pile and a hypertrophied papilla in the pectinate line [10]. The earliest surgical procedures included dilatation of the anal canal. In 1829 Recamiere introduced the technique of divulsion of the anus to reduce the sphincter spasm; at present, the technique is known as Lord´s procedure - it was also used to treat third degree haemorrhoids [14]. A carefully performed divulsion of the anus provides a 94% cure with a transient faecal and flatulent incontinence, underwear soiling in 13% of patients following the surgery. Other procedures consisted of a relatively broad excision of the fissure with a portion of the sphincter and anoderm; those procedures, however, delayed wound healing and resulted in a significant percentage of patients incontinent of stool. The plasty with a V-Y skin flap shift was also employed to reduce wound healing.
German authors have reported their experience in the treatment of 470 patients showing that excision of the anal fissure without sphincterotomy results in cure with a relatively low percentage of complications, such as underwear soiling, in 3.1% of patients [15].
It is worth remembering that on excision of anal fissure, sections should be examined histopathologically. Currently, the best surgical technique employed in the treatment of anal fissure is the lateral subcutaneous internal sphincterotomy which has been in use since 1959. It is highly effective, with a low recurrence rate and a significantly lower percentage of patients with faecal and flatulent incontinence [16]. In the study, the focus was also placed upon faecal incontinence prior to treatment, a pathology accompanying anal fissure [17]. Initially, sphincterotomy was performed at the site of anal fissure, with frequently resulting deformities of the anus causing subsequent underwear soiling and varying severity of faecal incontinence. At present, it is recommended to carry out a lateral procedure in a healthy tissue. Some reports show an increased patient comfort following a concomitant resection of the sentinel pile and hypertrophied mucosal folds. The procedure relieves pruritus, the sensation of a ´wet anus´ and ´a sticking out foreign body´ [18]. It also worth remembering that this method cannot be used in all patients. Caution is recommended in employing the lateral sphincterotomy in elderly patients, those with irritable bowel syndrome and recurrent anal fissure following previous surgery [19]. Sphincterotomy should not be carried out in women with anal fissure developing in the course of pregnancy, since studies have shown that sphincter pressure is low and the anal fissure is usually due to constipation [20]. In such cases it seems reasonable to perform anal manometry to precisely assess the sphincter pressure. A large number of conservative and surgical therapeutic methods in anal fissure indicates that there is no ideal, 100% effective treatment to be used in all the clinical varieties of the condition. It seems, however, that in view of a high cure rate, the therapy should be initiated with conservative treatment and patient education; ultimately, a failed treatment and a recurrent condition require a surgical operation [21].
Piśmiennictwo
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