2020年10月25日星期日

hemorrhoids and anal fissures,Understanding anal fissure

    Anal fissure

    Anal fissure is a small ulcer formed after laceration of the skin layer of the anal canal below the dentate line. Its direction is parallel to the longitudinal axis of the anal canal and is about 0.5 to 1.0 cm long. It is fusiform or elliptical and often causes severe pain and difficult healing. The surface laceration of the anal canal cannot be regarded as an anal fissure that heals itself quickly and is often asymptomatic. Anal fissure is a common anal canal disease and a common cause of severe pain in the anal canal for young and middle-aged people. Anal fissures are most common in middle-aged people, but it can also occur in the elderly and children. Generally, men are slightly more than women, but there are also reports of more women than men. Anal fissures often occur in the back and front of the anus, mostly in the back of the anus, and less on both sides. At first, there was only a small crack in the skin of the anal canal, and sometimes it can split into the subcutaneous tissue or as far as the superficial sphincter. The breach is linear or prismatic. If the anus is opened, the wound surface of the breach becomes a round or oval crack.

    A new theory of anal fissure-impactation theory

    The so-called impaction theory refers to the impaction of objects in the anorectum (various primary lesions), which hinder defecation. During defecation, the anal canal expands beyond the limit, and the skin of the anal canal is cracked to form an anal fissure [1].

    1 Hypothetical reasoning

    There is an impaction in the anorectum with a mass that hinders the discharge of stool. To discharge the stool, one must work hard. The external force causes the caliber of the anal canal to be enlarged, the skin of the anal canal is torn, and anal fissures are formed.

    If the internal hemorrhoids, rectal tumors, hypertrophic anal papillae, and secret fecal masses are considered as impacted masses in the rectum, this also leads to anal fissures.

    In other words, why can’t we treat various primary lesions such as hemorrhoids, rectal tumors, hypertrophic anal papillae, and secret fecal masses as a kind of internal rectal impaction? This is the new concept of the cause of anal fissure Cypriot theory.

    2 Comparison and verification Compared with traditional theory:

    (1) Anatomy of anal fissure The anatomical structure of anal fissure is a congenital condition that anal fissure is prone to occur in special parts of the anus, rather than the direct factor of the formation of anal fissure, that is, the root cause of the formation of anal fissure without impaction factors.

    (2) The theory of traumatic impaction factor is the direct factor of the condition of trauma, and traumatic injury is the result of impaction factor hindering defecation.

    (3) Infection theory of anal fissure Infection can occur after the formation of anal fissure, which is a condition for the anal fissure to become chronic, or it can occur before the formation of anal fissure, which is a condition for hemorrhoids to aggravate or transform.

    (4) The theory of internal sphincter spasm. Chronic inflammation stimulates internal sphincter spasm and anal canal stenosis is the pathological change during the development and change of the anal fissure, not the cause of the anal fissure.

    3 Clinical verification

    In clinical research, the author thoroughly treats internal hemorrhoids, hypertrophic anal papilla, rectal tumor, constipation and other primary diseases based on the "impactation theory" and the principle of "using general purpose" as the treatment principle of anal fissure cases. Lesions-impaction factors, all received healing effects.

    In summary, the author believes that the use of "impactation theory" to summarize the pathological factors of anal fissures to explain the occurrence of anal fissures and to guide the treatment of anal fissures is better than other theories. The author believes that using "impactation theory" theory to study the formation of anal fissures has high academic and clinical value.

    【Sickness】

    The clinical symptoms of anal fissure [2] are pain and bleeding.

    Anal fissures often occur in the back and front of the anus, mostly in the back of the anus, and less on both sides. At first, there was only a small crack in the skin of the anal canal. Sometimes it can split to the subcutaneous tissue or to the superficial sphincter. The crack is linear or prismatic. If the anus is opened, the wound surface of the split becomes round or elliptical. The pain is very characteristic, that is, sudden knife-like pain during defecation (due to the skin of the anal canal being cut by the stool), and then relieved briefly, and then prolonged anal pain (due to spasm caused by the stimulation of the anal sphincter ). It is common in clinical patients to have a vicious cycle of "fear of pain-endure the stool-dry stool-more pain" because of fear of pain. Bleeding caused by anal fissure is also more or less due to the degree of torn blood vessels. It is common for cases of anemia due to long-term or massive bleeding from anal fissure.

    If the anal fissure is not treated in time in the early stage, there will be three kinds of symptoms: anal ulcer (fibrosis of the fissure, also known as old anal fissure), anal papillary hypertrophy (polypoid tumor), sentinel hemorrhoids (skin tag hyperplasia), continue Anal sinusitis (chronic inflammation of the anus) and anal fistula (purulent inflammation of the anus) may also develop, which is collectively called the "five features of anal fissure" with the first three symptoms. There is also the possibility of anal canal cancer due to long-term chronic inflammatory stimulation.

    The typical symptoms are pain, constipation, and bleeding. Dry and hard stools directly squeeze the ulcer surface and prop up the cracks during defecation, causing severe pain. The pain is temporarily relieved after the stool is discharged. After a few minutes, the sphincter reflex spasm causes intense pain for a long time, and some require analgesics. It can be relieved. Therefore, patients with anal fissure fear defecation, which makes constipation worse and forms a vicious circle. There may be a small amount of bleeding when the wound surface is open, dripping blood on the surface of the stool or after the stool. During the examination, use the thumbs of both hands to gently separate the anus orifice, and the ulcer can be seen. The newly-occurring anal fissure has a neat, soft edge, shallow ulcer bottom, no scar tissue, red color and easy bleeding. Chronic anal fissures are deep and hard, off-white, and not easy to bleed. Below the breach is a "sentinel hemorrhoid". Anal finger and anoscopy can cause severe pain in the patient and should not be performed.

    【Disease   Cause】

    The occurrence of this disease is mainly related to the following factors:

    1. Anatomical factors: the superficial part of the external anal sphincter, starting from the tailbone, forward to the back of the anus. Divided into two bundles, surround forward along both sides of the anal canal to the front of the anus and unite with each other. Therefore, there is a gap before and after the anus. And most of the levator ani muscles are attached to both sides of the anal canal, with fewer front and back. It can be seen that the front and back of the anus are not as firm as the sides, and they are easily damaged. And downward and backward form an angle of nearly 90 degrees with the rectum. Therefore, the back of the anus is more compressed by feces, and the blood circulation at the back of the anal canal is insufficient, the elasticity is poor, and the distribution of anal glands is more. These are all factors that cause anal fissures.

    2. Trauma theory: Dry and hard stools or foreign bodies can easily cause damage to the skin of the anal canal, which is the main cause of anal fissure.

    3. Infection theory: It is mainly an infection of the anal crypt in the back of the anus. The inflammation spreads to the lower part of the anal canal, causing the subcutaneous abscess to rupture and form an anal fissure.

    4. The theory of internal sphincter spasm: The anal sphincter is in a state of spasm due to injury or inflammation of the anal canal, which increases the tension of the anal canal and is easily damaged into anal fissure.

    5. Anal narrow elementary school said: The skin of the anal canal is slow in development, resulting in a narrow anal canal, which is easily damaged into anal fissure.

    【Disease  理】

    The pathological changes of anal fissure can be divided into four stages:

    Initial stage: Anal fissure caused by the above-mentioned factors, the initial skin damage of the anal canal, or a superficial ulcer, and the surrounding tissues are basically normal.

    Ulcer formation stage: bad granulation hyperplasia in the wound. At the bottom of the wound, there are circular fibers, and the skin at the edge of the wound is hyperplasia.

    Chronic ulcer stage: old wound ulcer, internal sphincter can be seen under planing.

    Chronic ulcers combined with other pathological changes: On the basis of chronic ulcers, there are subtly anal fistulas. Chronic anal fissures often have the following pathological changes.

    ① Anal papillitis: The upper end of the ulcer is connected to the tooth line, and the inflammation spreads, often causing anal sinusitis, and finally forming anal papilla hypertrophy.

    ② Anal sinusitis: Anal sinus infection spreads, small abscesses are formed under the skin of the anal canal, and ulcers are formed. Anal fissure first, then anal sinusitis.

    ③ Fusiform ulcer: anal canal skin laceration, after infection, the formation of ulcers.

    ④ Anal comb induration: that is, the chlamydia becomes thick and hard, forming a comb-like induration, which is exposed to the base of the ulcer, hindering the relaxation of the sphincter and affecting the healing of the ulcer.

    ⑤ Latent fistula: A fistula at the base of the anal sinus is often connected to an ulcer, which is caused by the formation of a small abscess and rupture due to infection of the anal sinus.

    ⑥ Split hemorrhoids: The skin at the lower part of the split is changed due to inflammation, and the superficial vein and lymphatic drainage are blocked, causing edema and tissue hyperplasia. The formation of connective tissue external hemorrhoids, also known as sentinel hemorrhoids.

    【Sub-category】

    The classification of this disease has not been unified at home and abroad. The clinically commonly used two-stage classification and three-stage classification.

    (1) The second-stage classification:

    ①Early anal fissure (acute stage): the fissure is fresh, no chronic ulcer is formed, and the pain is mild;

    ②Old anal fissure (chronic stage): Chronic ulcers have formed in the fissure, and there are also anal papilla hypertrophy, skin tags, etc., and severe pain.

    (2) Category 3:

    ① Stage I anal fissure: The skin of the anal canal has a superficial longitudinal fissure, and the wound edge is neat and tender. The tenderness is obvious and the wound is full of elasticity.

    ② Stage II anal fissure: there is a history of repeated attacks. The wound edge has irregular thickening and poor elasticity. The base of the ulcer is purplish red or has purulent secretions, and the surrounding mucosa is congested.

    ③Stage III anal fissure: The ulcer has hard edges, purplish red basement with purulent secretions, hypertrophy of the anal papilla near the anal sinus at the upper end, fissure hemorrhoids at the lower end of the wound, or subcutaneous fistula formation.

    【complication】

    If the treatment is not timely, the rupture will become inflamed and infected repeatedly, which will develop subcutaneously to the anal margin, and will also form subcutaneous abscesses and fistulas.

    Anal fissure is a common anal canal disease. Due to its long-term repeated infection, it affects people's lives and has a series of complications:

    1. The initial ulcer is a longitudinal slit in the skin of the anal canal, which is linear or prismatic, with soft and neat edges, shallow and elastic bottom. Repeated infections make the slit unhealed, thickened edges and hard base, and gradually become a deeper chronic ulcer , Slight stimulation can cause severe pain.

    2. Sentinel hemorrhoids The skin under the cleft is irritated by inflammation, which obstructs the flow of lymph and venules, causing edema and fibrosis, forming skin tags of varying sizes, called sentinel hemorrhoids, which are also connective tissue external hemorrhoids.

    3. Anal sinusitis and anal nipple hypertrophy are the result of repeated stimulation of inflammation at the upper end of the cleft. The nipple hypertrophy can protrude out of the anus with defecation.

    4. Anal marginal abscess and anal fistula The inflammation of the cleft expands to the subcutaneous, coupled with the sphincter spasm, the ulcer is not drained smoothly, the secretion sneaks into the subcutaneous of the anal margin, forming an abscess, and the pus ruptures to the cleft to form a subcutaneous fistula.

    5. Thickening of the combo The combo area is the narrowest area of ​​the anal canal, and is a prone area for comb induration and narrowing of the anal canal. The thickened tissue under the combo zone is called the combo belt. The inflammatory stimulus of anal fissure can make it thicker and lose its elasticity, hindering the healing of the anal fissure. Therefore, the thickened combo belt should be cut off when treating anal fissure.

    【Self-check】

    How to determine if you have an anal fissure

    Anal fissure is an ulcer formed after anal canal skin laceration, with anal pain, bleeding, constipation, and anal itching as the main symptoms.

    Whenever there is something wrong with the anus, the first thing people think of is "Will I have hemorrhoids". This is the case for many people with anal fissure bleeding. Because they don’t understand this disease, doubts and worries are increasing day by day. People who worry about it even think that this is a sign of bowel cancer. In fact, the difference between anal fissure and hemorrhoids and bowel cancer is very obvious.

    According to reports, the bleeding from anal fissures and hemorrhoids are bright red, but each has obvious characteristics. The former is painful when the amount is small, usually a few drops of blood on the toilet paper; the latter is large but painless and bleeding Usually more than 10 drops. Stool bleeding in patients with bowel cancer is often dark red, mixed with mucus or pus and blood, and the habit of defecation will be significantly changed, the number of bowel movements will increase, and the feeling of urgency and heaviness is also accompanied. If the diarrhea still fails to converge after medication, you should pay special attention. In addition, the three patients are not the same. Hemorrhoids and anal fissures may occur in people of any age, while patients with rectal cancer are mostly middle-aged or elderly.

    Patients with anal fissure should not do anal finger examination

    Anorectal examination has a good effect in the diagnosis of many anorectal diseases, and it is easy to operate, so it is one of the commonly used examination methods for anorectal doctors. But nothing is omnipotent, and anal fingers are no exception. For example, anal fingers cannot be used for anal fissure inspection.

    The typical symptoms of anal fissure are pain, constipation, and bleeding. Dry and hard stools directly squeeze the ulcer surface and prop up the crack during defecation, causing severe pain. The pain is temporarily relieved after the stool is discharged. After a few minutes, the sphincter reflex spasm causes intense pain for a long time, and some require analgesics. It can be relieved. Therefore, patients with anal fissure fear defecation, which makes constipation worse and forms a vicious circle.

    Home self-examination of anal fissure

    The clinical manifestations of anal fissure [3] mainly include pain, bleeding, constipation, anal itching and other symptoms. We can conduct self-examination at home through the symptoms of anal fissure [4]. If you have these symptoms, then go to the hospital for treatment. Right. ① Whether it is painful: It is mainly manifested as severe pain, persistent severe pain, which can continue to aggravate, and can be relieved automatically after a few hours. ②Bleeding: When defecating, the wound is injured, which can cause bleeding from the crack.

    【Diagnosis and diagnosis】

    The symptoms of anal fissure have clear characteristics. As long as the history of the disease and the characteristics of pain and bleeding are examined in detail, the diagnosis is not difficult. However, in order to improve the accuracy of the diagnosis and prevent mistakes during diagnosis, the differential diagnosis should be strictly based on several aspects of questioning, palpation, inspection, and biopsy.

    Inspection: Excretion can be seen in the anus of acute anal fissure, and the lower end of the anal fissure can be seen when the buttocks are retracted. If the lower end of the fissure is lightly touched with a probe, it can cause pain; chronic anal fissures often have connective external hemorrhoids.

    Digital examination: due to sphincter spasm, the anus is tightened. Excessive force often causes severe pain. Sometimes it is necessary to check under local anesthesia. For the cracks felt in the anus, acute patients have soft edges, shallow bottom, elastic, and sensitive to touch; chronic patients have hard protruding edges, deep bottom, and no elasticity.

    Speculum examination: oval ulcers or small cracks can be seen. Acute anal fissures have neat edges and light red bottom; chronic anal fissures have irregular edges and dark gray-white bottoms. In some severe anal fissures, sphincter fibers can also be seen.

    Differential diagnosis: It must be differentiated from tuberculous ulcer, syphilis ulcer, chancroid and epithelial cancer. Anal fissures complicated by ulcerative colitis and granulomatous colitis are easy to distinguish.

    [Identification method]

    Anal fissures may have one or several fissures, but most anal fissures occur on the midline, directly before or after, that is, at 6 o'clock and 12 o'clock in the stone cutting position. Due to the dryness of feces, the skin of the anal canal is scratched when passing through the anus. Generally, it cannot be called anal fissure. Because the feces are dry and hard, the wound made by tearing the anal canal through the anal canal is called anal fissure. The depth of damage varies. Shallow anal fissures only lacerate the skin of the anal canal, while deep anal fissures can damage subcutaneous tissue to muscle tissue, or even muscle tissue.

    The difference between hemorrhoids and anal fissure

    Most anal fissures are accompanied by sentinel hemorrhoids, especially those who have been neglected for a long time. After the development of old anal fissures, they are often accompanied by external hemorrhoids and internal hemorrhoids. At this time, the appearance of the two outside the anus is basically the same. Therefore, understanding the difference between anal fissure and hemorrhoids and raising awareness of anorectal abnormalities are of great benefit to treatment.

    Anal fissure is the main manifestation of anal canal skin cracks, anal canal ulcers, and difficulty in healing. Hemorrhoids are caused by the formation of varicose veins, venous vascular clusters in the veins around the anus, and the sliding of the mucous membrane of the lower rectum.

    1. Anal fissure is mainly pain and blood in the stool. Hemorrhoids are mainly bleeding, and only when the external hemorrhoids are inflamed and swollen, the hemorrhoids will be painful.

    2. Anal fissures can be seen with anal canal skin splits, but hemorrhoids are not. It can be confirmed during digital anal examination, but digital anal examination or speculum examination is often not feasible for anal fissures;

    3. Anal fissures are often accompanied by anal papillary hypertrophy and anal papilloma, while hemorrhoids are not accompanied by anal papillary hypertrophy or papilloma;

    4. In patients with anal fissure, the appearance of the anus can be narrowed, while in patients with hemorrhoids, prolapse and eversion of internal hemorrhoids are more common.

    Anal fissure must be differentiated from the following diseases

    1. Anal skin chapped: mostly caused by anal pruritus, anal eczema, etc. The crack is superficial and short, does not reach the anal canal, pain is light and bleeding is less, itching is heavier, and there are no complications such as ulcers, split hemorrhoids and anal papilla hypertrophy .

    2. Anal tuberculosis: ulcers are irregular in shape, with a sneaking edge, light pain, no split hemorrhoids, tuberculosis nodules and caseous necrotic lesions can be seen during pathological examination.

    3. Anal skin cancer: The ulcer is irregular in shape, the surface is uneven, the edge is raised, hard, and has a strange smell and persistent pain. Cancer cells can be seen in the pathological section.

    【Treatment】

    Fresh anal fissure

    Healing can be achieved by non-surgical treatment, such as a local hot water bath, and potassium permanganate solution after the toilet, which can promote the relaxation of the anal sphincter; apply anti-inflammatory analgesic ointment (including dicaine, berberine, metronidazole) Etc.) to promote the healing of ulcers; oral laxatives can make the stool soft and lubricated; for severe pain, procaine can be used to partially seal or retain enema to relax the sphincter.

    Old anal fissure

    After the above treatment is ineffective, surgical resection, including ulcers and skin tags (sentinel hemorrhoids) can be removed together, and some external sphincter fibers can be cut, which can reduce postoperative sphincter spasm and facilitate healing. The wound is not sutured and defecation is maintained after surgery Unblock, hot water bath and dressing of the wound until healed completely.

    There are roughly the following methods of surgical treatment:

    1. Resection: It is suitable for stage Ⅲ or chronic anal fissure, with good postoperative effect and very little recurrence.

    2. Rear internal sphincterotomy: The main purpose is to eliminate internal sphincter spasm.

    3. Lateral internal sphincterotomy: The main purpose is to reduce and prevent anal dysfunction.

    4. Anal canal dilation: mainly used for the loss and contraction of anal canal elasticity, sphincter dysfunction, and organic stenosis caused by various reasons.

    5. V-Y anal canal plasty: suitable for skin defects of the anal canal and obviously narrow anal fissures.

    6. Treatment of skin cracks around the anus: surgery should be selected according to the cause of the disease.

    7. Anal fissure with stage Ⅰ or small stage Ⅰ hemorrhoids: a lateral internal sphincterotomy should be performed first, and injections for the treatment of internal hemorrhoids after the anal fissure is cured.

    Other therapies: such as laser, electrocautery treatment, etc.

    Principles of treatment of anal fissure

    The principle of treatment of anal fissure is that the treatment of acute anal fissure is based on conservative treatment, namely non-surgical treatment, which should relieve pain and stop bleeding to prevent the vicious circle of pain. For chronic anal fissures or stage III anal fissures, surgical treatment should be given priority to completely eliminate the causes of anal fissures and factors that aggravate pain.

    (1) Maintain smooth stools and prevent constipation: Eat more vegetables and fruits, increase drinking water, and correct constipation. Laxatives or paraffin oil can be taken orally to make the stool soft and smooth to facilitate defecation.

    (2) Local sitz bath: Sitz bath with hot water or warm potassium permanganate water at a temperature of 40℃~50℃ (2~3 times a day, 20-30 minutes each time. Warm water sitz bath relaxes the anal sphincter and improves local blood Circulation, promote the absorption of inflammation, relieve pain, and clean the local area to facilitate wound healing. After taking a bath, anti-inflammatory and analgesic drugs can be applied externally to relieve symptoms.

    (3) Occlusion therapy: For severe pain, use 1% to 2% procaine to inject into the base of anal fissure and the anal sphincter on both sides to relieve sphincter spasm and relieve pain.

    (4) Anal canal dilatation: It is suitable for patients with acute or chronic anal fissure without complicated nipple hypertrophy and sentinel hemorrhoids. Using fingers to expand the anal canal under local anesthesia or sacral anesthesia can relieve the anal sphincter spasm and achieve the purpose of pain relief.

    (5) Surgical treatment: Surgical treatment can be used for chronic anal fissures that do not heal for a long time and are ineffective in non-surgical treatment.

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