The anus is the anal canal, and the fissure is split. Anal fissure is the surface split of the narrowest anal canal tissue from the dentate line to the anal edge of the digestive tract, forming small ulcers, the direction is parallel to the longitudinal axis of the anal canal , Fusiform or oval, about 0.5 ~ 1.0cm long, often cause severe perianal pain. The most common site of anal fissure is the posterior midline of the anus. The incidence of anal fissure accounts for about 20% of anorectal diseases, and it is mostly young people, but anal fissures are more favored by women, especially young women. The incidence of Chinese women is about 1.8 times that of men, and the result reported by the Japanese Colonic Society is 1.6 times. Anal fissures can be divided into acute and chronic. Chronic anal fissures have a long course and recurring episodes. The anal flap and anal papilla at the upper end of the fissure are edema, causing the anal papilla to become hypertrophy, and the skin at the lower end is pouched down and protruding outside the anus, forming a "sentinel" Hemorrhoids, anal fissure, sentinel hemorrhoids, and anal papillary hypertrophy often exist at the same time, which is called anal fissure triad.
1. Abnormal stool
Anal fissure is firstly caused by impact or friction from external forces. If the stool is too thick and hard, the anal adaptability is poor at this time, which will cause the anal canal to split. Some studies have found that not only constipation, but also diarrhea can also cause anal fissure, which can account for 4% to 7% of the cause of anal fissure.
2. Internal sphincter spasm
Inflammatory stimulation of the intestines, anal canal or anal sinus, acidic stool stimulation, sphincter exposure, anger and tension and other abnormal emotions can cause high tension of the internal anal sphincter, which can cause a significant increase in the resting pressure of the anal canal, and the stretchability of the anus at this time Not enough, when hard feces pass through, cracks will occur.
3. Anatomical defects
The external anal sphincter forms two triangular fissures before and after the anal canal, which lacks sufficient support for the anal canal, but it can crack when feces impact. At the same time, the anal arteries are distributed from both sides to the middle, and cross the anus front and back. As a result, two weak areas are formed before and after the anus, resulting in poor blood supply in this area. The anal canal and the rectum continue at a 90-degree angle. The posterior wall of the anal canal bears the greatest pressure during defecation, so anal fissures are most likely to occur at the posterior midline.
The typical clinical manifestations of anal fissure are pain, blood in the stool and constipation.
It is the most important symptom of anal fissure. The degree and duration of pain indicate the severity of anal fissure. A typical anal fissure pain cycle is: pain-relief-peak-relief-pain again. Stool stimulates the nerve endings on the ulcer surface during defecation, causing severe burning or knife-like pain after defecation, which can radiate to the buttocks, perineum, sacrum or inner thigh, which is called pain during defecation. The pain relieved a few minutes after going to the toilet, this period is called the pain intermittent period. Later, due to internal sphincter spasm, severe pain occurs, which lasts for several minutes or several hours. At this time, the patient will be restless and unbearable. After the sphincter fatigue, the muscles relax and the pain gradually relieves. After defecation again, the pain occurs again.
2. Blood in the stool
Dripping blood during defecation or rubbing blood on paper after defecation is the main form. The blood is bright red. The amount of bleeding is related to the depth and size of the crack, but it will not spurt like hemorrhoids and rarely hemorrhage. Anal fissure blood in the stool will also periodically recur.
Many patients with anal fissure themselves have constipation. After suffering from anal fissure, some patients are afraid of defecation due to pain in the anus. Over time, the stool will become more dry and hard, and the constipation can aggravate the anal fissure, which forms a vicious circle.
Anal fissure examination is also very simple. It does not require special equipment and can be completed in the anorectal clinic. But be careful, you can see and touch, but don't use anal mirror casually, to avoid causing more pain and anal laceration to the patient.
(1) Look at the "sentinel hemorrhoids" Patients with anal fissures generally grow epidermis on the front and back sides of the anal margin. This is called "sentinel hemorrhoids" in clinical practice and is one of the important signs of anal fissure.
(2) The crack is located in the front and back center of the anus, and you need to gently pull the anus to see it. See if the crack is fresh and deep. Sometimes you will see white inside the breach, which means it is deeper and has split to the fascia tissue on the surface of the internal sphincter.
Digital examination of anal fissures must be gentle, gentle, and gentle.
(1) Touch the tension of the anal canal. Put more lubricating oil on the finger cot, gently put it into the anal canal, feel the tension of the anal canal, and judge the severity of the anal fissure. Excessive tension in the anal canal should be treated even if there is no crack.
(2) Touching scar tissue and fistula. The severity of scar tissue indicates the course and prognosis of anal fissure. Subcutaneous fistula with anal fissure also requires digital examination to judge.
(3) Touch the anal nipple. Patients with anal fissure should try not to use an anal mirror. You can use your fingers to check whether there is anal nipple hypertrophy.
Based on the medical history, typical clinical symptoms and findings during examination, it is not difficult to diagnose. If the edge of the anal fissure is soft and tidy, the bottom is shallow, there is no scar, the color is pale red, and it is easy to bleed, indicating an acute anal fissure. If there is a scar around the cleft, the bottom is irregular, it is grayish white, it is not easy to bleed, and there is an "anal fissure triad", which indicates chronic anal fissure.
Most patients with chronic anal fissure correct primary constipation or diarrhea, or use clinical topical drugs for experimental treatment. Patients with poor conservative treatment can consider anal fissure resection and/or internal sphincter lateral resection. Acute or initial anal fissures can be cured by increasing fiber and water intake and warm water bathing.
1. Correct bowel abnormalities
Constipation is one of the main symptoms of anal fissure, and it is also the main reason for the formation of anal fissure. It can be used to soften the stool and keep the stool smooth by increasing dietary fiber food or supplementing vitamins with drugs. Constipation can be added with laxatives and probiotics.
2. Clean the anus, take a bath
After defecation or before going to bed, use 1:5000 potassium permanganate warm water to bathe to keep the area clean.
3. Local medication
(1) Analgesics. Anesthetics (such as lidocaine gel) and non-steroidal anti-inflammatory drugs (such as diclofenac cream, ibuprofen cream, etc.) can relieve pain symptoms.
(2) Promoting crack healing, hemorrhoid cream, recombinant human epidermal growth factor, etc.
(3) Topical application of nitroglycerin ointment: Apply 0.2% nitroglycerin ointment to the anal fissure, 2 times a day, for 5 to 8 weeks. The drug can inhibit neurotransmitters and relax smooth muscles and expand blood vessels. The internal sphincter is relaxed, the pressure of the anal canal drops, and the local blood circulation is improved.
(3) Local injection of botulinum toxin A small dose of toxin has the effect of weakening the tension of the internal sphincter. Inject 0.1ml of diluted botulinum toxin through the external sphincter next to the anal fissure, resulting in chemical denervation and local muscle paralysis, thereby reducing muscle tension.
Suitable for patients with acute or chronic anal fissure not complicated by nipple hypertrophy and sentinel hemorrhoids. Dilation of the anus with fingers or instruments (the bell mouth anoscope commonly used in anorectal medicine can be used) has a certain effect on relieving severe anal pain, but it will recur, and may be complicated by anal hematoma, bleeding, and short-term anal incontinence.
5. Surgical treatment
It is suitable for chronic anal fissures with triad of anal fissures or non-surgical treatments. Commonly used surgical methods include anal fissure resection and lateral internal sphincterotomy.
Anal fissures generally do not become cancerous, but if they are not treated in time, the wounds can become infected. Inflammation spreads to the anus, can cause anal papilla hypertrophy, sentinel hemorrhoids, etc., if the disease continues to progress, it can also cause anal sinusitis and anal fistula.
It is important to maintain a relaxed and happy attitude. The treatment and prevention of constipation is the most important way to prevent anal fissure recurrence. Pay attention to the hygiene of the anus, and develop the hygienic habit of cleaning the anus in time after defecation. Anal sinusitis, anal papillitis, perianal eczema, perianal skin diseases and other perianal inflammatory diseases should be treated in time. Doing these can effectively prevent the occurrence and recurrence of anal fissures.
A typical anal fissure pain process is: pain-relief-peak-relief-pain again. Anal fissure examination is very simple and does not require special equipment and can be completed in the anorectal clinic. But pay attention, you can see and touch, but don't use anal mirror casually to avoid aggravating pain and anal laceration.
Department of Anorectal, Tongchuan District Hospital of Traditional Chinese Medicine, Dazhou City