IAS internal anal sphincter
EAS external anal sphincter
RAP resting anal pressure
BT botulinum toxin
GTN glyceryl trinitrate
ISDN isosorbide dinitrite
Objective: To observe the clinical efficacy of Kangche ointment in the treatment of fresh anal fissure and to explore its internal mechanism.
Results: In the test group, 18 cases were cured (60%), 12 cases were effective (40%), and the total effective rate was 100; in the control group, 15 cases were cured (50%), 10 cases were effective (33.34%), and the total effective rate (83.34%) . There was no significant difference in the overall curative effect between the two groups. P>0.05, the test group and the control group had no significant difference in the degree of pain before treatment, and the degree of pain after treatment was significantly lower than before treatment. There was a difference in the degree of pain between the two groups after treatment Significant meaning. The difference in pain between the test group and the control group before and after treatment was extremely significant (P<0.001). It shows that Kangche ointment is better than Xiongdan Zhiling ointment in relieving anal pain in patients with anal fissure. There was no significant difference in blood in the stool before treatment between the two groups, and blood in the stool was significantly reduced after treatment. The difference in blood in the stool after treatment between the experimental group and the treatment group was significant. The comparison of the number of stools per week before treatment and the number of stools per week after treatment between the two groups of patients was statistically processed, and the difference was significant. The test group and the control group had a significant difference in the time required for each bowel movement before treatment. After treatment, the treatment group had a shorter average bowel time than the control group. The difference between the two was statistically significant (P<0.05)
Conclusion: Kangche ointment can reduce the tension of the internal anal sphincter, relieve internal sphincter spasm, reduce the resting pressure of the anal canal, and has the effect of promoting wound healing, and also helps to lax. It has a good therapeutic effect on anal fissures.
Keywords: Kang crack paste
Object:to observe the clinical therapy effect of kang lie gao for anal fissures
Methods:We divided 60 cases of anal fissure patients into two groups randomly from May 2004 to October 2006.The treatment group modified with kang lie film.The control group modified with xiong dan zhi ling ointment.we compared and analyzed the two groups on the situation of healing of fissures,bleeding, anal pain, stool frequency and defecation time
Results: In kang lie film group,60% healed and 40% improved. In control group, 50% healed and34.33% improved (P>0.05). Compared with the control group, kang lie film has better effects in anal pain relief . There is no significant difference about blooding between the kang lie group and the control group before treatment,while After treatment, the two groups both have better effects in blooding relief and the kang lie film is better. After treatment, the per defecation time is shorter in Anocure film group than control (P<0.05).
Conclusion: The kang lie film can reduce the IAS hypertonia, relaxes the spasm of IAS, reduces RAP and accelerate wound healing. It has a good result on anal fissure treatment.
Key words: anal fissure;kang lie film; clinical researchment
Anal fissure is a common disease, and its incidence is 20% of anorectal diseases, second only to hemorrhoids. It is also called split hemorrhoids in Chinese medicine. It is a non-specific radial longitudinal ulcer of the anal epithelium, which is fusiform or elliptical, and is more common in the anus. It is rare in the rear part, followed by the front part, on both sides, young and middle-aged people are prone to be affected, and there are more men than women. The cause is unknown. It may be related to anal anatomy, injury, infection, constipation and congenital anal stenosis. The main clinical manifestations are persistent cramping pain in the anus, bleeding during stool, and constipation. The pain of anal fissure is severe, and the patients are often unbearable. At present, Western medicine mainly focuses on surgical treatment. The internal sphincter is cut to relieve the spastic pain. Although the effect is significant, the side effects are large, and there is a risk of defecation incontinence. . However, Chinese medicine is different. Chinese medicine believes that anal fissures are mostly caused by blood heat and intestinal dryness, blood deficiency and intestine dryness, accumulation of damp-heat, stagnation of qi and blood stasis. The treatment is based on overall syndrome differentiation, including surgery, oral Chinese medicine, external fumigation, application, and acupuncture. The combination of massage and even qigong has achieved good results. Among them, topical ointment has a certain viscosity, and gradually melts after external application, so that the medicine is slowly absorbed and the effect is lasting. It is economical and practical, and the curative effect is conclusive. It has been praised by doctors in the past and is still widely used. Kangcha ointment is a kind of pure Chinese medicinal ointment that came into being to relieve the pain of patients with fresh anal fissure. Developed by Guo Chunyan's instructor, it takes healing blood to relieve pain, soothing wind and moisturizing dryness, and has received good clinical effects.
In this study, by observing the difference in the degree of pain, pain time, blood in the stool, and defecation time before and after the application of Kangche ointment in fresh anal fissure patients, the exact effect of Kangche ointment was confirmed without obvious adverse reactions, which is worthy of clinical promotion.
1 TCM understanding of anal fissure
1.1 The understanding of traditional Chinese medicine on anal fissure
China is one of the earliest countries in the world to recognize anorectal diseases. The ancient Western Han Dynasty book "Fifty-two Remedies" unearthed in Mawangdui, Changsha, Hunan, records male hemorrhoids, hemorrhoids, pulsed hemorrhoids, blood hemorrhoids, intestinal hemorrhoids, and nest. Patients, people state out and other anorectal diseases1. From the "Emperor's Internal Classic", Chinese medicine has classified anal fissures in the category of hemorrhoids. The "Internal Classics · Qi Tongtian Theory" says: "The wind is offensive, the essence is death, the evil damages the liver, so it is full and the muscles and veins are relieved. , The intestines are hemorrhoids". It is believed that anal fissure and hemorrhoids are caused by self-doubling of diet, gastrointestinal injury, yin and yang discordance, stagnation of the diaphragm, heat toxin injection, and blood infiltration into the large intestine. Chao Yuan's prescriptions in Sui Dynasty are in "Theories on the Origin of All Diseases" 2. For the first time, he described the shape of anal fissures. He said, "Long anal fissures, itching and recurring pain and bleeding, pulse and hemorrhoids." Song Dynasty "Sanji Zonglu·Hemorrhoids and Fistula Gate" explained the causes and symptoms of the five hemorrhoids one by one. After analysis, it is believed that "Patients with pulse and hemorrhoids have sores on the anal side, itching and recurring pain, and bleeding. The internal organs accumulate, and the wind-heat cannot be passed through. The wind-heat gas flows to the lower part by the deficiency, so the anal side has sores. , Itching and blood flow out, it is pain, but it is itchy when it is empty. Now the actual heat hits the large intestine, so itching and pain, and the pulse is the blood of the viscera, and if the heat is hot, the blood goes out. The typical features of fissures are pain in the anal, bleeding, and blood hemorrhoids during defecation, which seem to be more in line with the symptoms of anal fissure. The same is the "Sanji General Record · Hemorrhoids and Fistula Gate": "Blood hemorrhoids, it is also possible to clear blood due to stool. The argument says: People with blood hemorrhoids, the lungs are hot and poisonous, the lungs and the large intestine are both on the outside and the inside. Today, the lungs contain hot and toxic air currents, which penetrate into the large intestine, and the bloody heat will dissipate. Therefore, the anorectal pain is severe due to stool, and the blood is cleared. ". It was not until the Qing Dynasty that Qi Kun’s "Surgery Dacheng" had a clear understanding of the three major characteristics of anal fissure pain, bleeding, and constipation, and proposed specific treatments: "Hookintestinal hemorrhoids, hemorrhoids inside and outside the anus, broken creases, The stool is like sheep dung, bleeding after the feces, and bad smelling pain. Take health-preserving pills, fumigate and wash for external use, put the dragon musk pill in the valley every night, and receive power in one month." The name of anal fissure was first seen in Qing Ma Peizhi’s 72 types of Mar’s hemorrhoids, among which there are anal fissures. 3
1.2 Discussion on the etiology of anal fissure in traditional Chinese medicine and the relationship between anal fissure, hemorrhoids, intestinal wind and visceral poison
1.2.1 Discussion on the etiology of anal fissure in traditional Chinese medicine
Since traditional Chinese medicine considers anal fissure as a type of hemorrhoids, the knowledge of the cause of hemorrhoids essentially includes knowledge of the cause of anal fissure. Sui Chaoyuan Fang believed that "all hemorrhoids are caused by colds and accidental intercourse." "Jingyue Quanshu" 4 Said: "Hemorrhoids belong to the three meridians of the liver, spleen and kidney. Those who lose the yin meridian are difficult to treat, and most of them become fistula. If the lung and large intestine meridians are wind-heat and damp-heat, the heat subsides spontaneously. "Shengji Zonglu" states that the shape of hemorrhoids is derived from "the transmission of the five internal organs and the reception of the large intestine." Qing Huang Yuanyu detailed the relationship between the internal organs and hemorrhoids in "Four Sacred Heart Source" 5. He believes that “hemorrhoids are also the disease of the hand sun. The hand sun disease is caused by the sinking of the fire and the cold water, which is caused by heat in the small intestine. The disease of the internal organs is transmitted to it, and the fire is transformed into gold. Heat transfers to the large intestine, at the end of the large intestine at the Pomen, and Binghuo transfers the gold to the bottom, so hemorrhoids are born in the anus. If the lung qi is not clear, the spleen soil is collapsed, the liver wood is stagnant, and the kidney veins are slightly astringent. But the blood does not go up, so it is lost in the stool, and the flow is the sinking of hemorrhoids." And put forward the cause of hemorrhoids in coldness: "This disease is 10%. On weekdays, when hemorrhoids develop anal fever, they are in the period of cold and dampness, and the work is not known." "The Secret Record of Feng's Tips" 6 thinks that hemorrhoids can be affected by the fetus, saying: "Hemorrhoids, near the anus Sores, swelling and pain are also caused by the mother’s food, wine and noodles-burning in the fetus.” He also believed that hemorrhoids are related to the four qi of exogenous dampness, heat and fire: Qi also, for the sick, is also hot and humid. It is caused by excessive drinking, dampness and heat generation. It fills the viscera, overflows in the meridians, falls in the valley, and conflicts between left and right as hemorrhoids. "Traditional Tibetan medicine believes: 7 "Excessive diarrhea, damage to the enema, congestion, obstruction, riding, sitting on a hard seat, and 8 vomiting dragon disorder can all induce hemorrhoids." It also puts forward the daily health care methods for preventing and curing hemorrhoids, such as avoiding constipation, excessive force during defecation, sedentary hardness, riding, dampness, fire, sun exposure, and extreme heat.
1.2.2 The relationship between anal fissure, five hemorrhoids, intestinal wind and visceral toxin
The ancients realized early on that although anal fissure, five hemorrhoids, visceral toxins, and intestinal wind all have blood in the stool, their etiology and pathogenesis are different, and the symptoms of bleeding are also different. Xu Xueshi said 9 "Those who have clear blood and fresh blood will have intestinal wind; those who shoot blood from the anus will have pulses and hemorrhoids." "Chen Yanyun" 10: "Intestinal wind, the foot Yangming will accumulate heat for a long time and become wind. There is also to move; dirty toxins are enough to accumulate heat in the lunar yin for a long time and produce dampness, which is indecent. The wind will receive the sun, and the wetness will receive it." "Jingyue Quanshu" says: "People only sit and lie down with rheumatism and get drunk. In the full-worked room, the wine area is hot, which has caused the blood to lose its way and infiltrate the large intestine. This intestinal wind is the cause of the dirty and poison. Those who carry heat and blood will be clear and fresh, and those who carry cold blood will be turbid and color. Dark and clear are intestinal wind, while ulceration is visceral poison.” Key 11 says: “Dirty toxins, those who accumulate poisonous gas for a long time, start with intestinal winds, and evil spirits come in as you feel.” “Three Causes” said There is a fundamental difference between intestinal wind, visceral toxins and anal fissures and hemorrhoids, saying: "Dirty poison, the blood of intestinal wind comes from the intestines, and the blood of five hemorrhoids comes from the anal pits.
1.3 Modern Chinese medicine's understanding of anal fissure
1.3.1 The concept and epidemiology of anal fissure
Modern Chinese medicine refers to anal fissure as anal fissure, also called anal fissure hemorrhoids, fissure hemorrhoids or hook intestinal hemorrhoids. In a broad sense, anal fissure should be a general term for all cracks in the anus, including cracks caused by anal fissure, anal fissure, tuberculous ulcer, syphilis, Crohn's disease and ulcerative colitis. But clinically, the so-called anal fissure in traditional Chinese medicine refers to the deep and full-thickness laceration of the skin of the anal canal under the dental line, accompanied by infectious ulcers. Anal fissures are mostly fusiform or oval, about 0.5-1cm in length, most of them are found in the middle of the posterior anal canal. Preanal fissures are more common in women, but not more than 10%, while only 1% of male anal fissures are Preanal fissure. Anal fissures are more rare on both sides. Anal fissure is a common disease in the anorectal department. The incidence of anal fissures accounts for 20% of anorectal diseases.12 It is second only to hemorrhoids and can be affected by both males and females. The general survey in China shows that the incidence of anal fissures is higher in women than in men, and is more likely to occur in age. 20-40 young adults, the elderly and children are less common, especially young women who have more morbidity. This may be related to women's easy constipation after pregnancy and often tearing of the anal canal and perineum during childbirth. Unmarried young women are susceptible to anal fissures, especially menstrual periods, which are likely to get worse, which may be related to perineal hyperemia during menstruation.
1.3.2 Modern Chinese medicine understanding of the etiology and pathogenesis of anal fissure
Modern Chinese medicine believes that the occurrence of anal fissure is mostly caused by dry fire, damp-heat accumulation in the anus, blood deficiency intestinal dryness and stagnation of qi and blood stasis.
1) Intestinal dryness with blood heat: due to overeating fat and sweet taste, drinking strong alcohol, over taking warm medicine or supplements, or unclean residual heat after high fever, etc., feeling wind, fire, dryness, heat evil, etc., drying out over time In the gastrointestinal tract, the body fluid is burned and the intestinal tract is depleted, making the stool hard and dry and difficult to discharge. It damages the anus and causes a crack. The crack is repeatedly deepened due to constipation, and the anal fissure is formed after a long time.
2) Damp-heat accumulation: body fat, exogenous damp-heat evil, addiction to alcohol, wine, fat and sweetness, and even damp-heat accumulation in the stomach and intestines, betting anal carbuncle, carbuncle ulceration does not heal, and anal fissure.
3) Intestinal dryness due to blood deficiency: for the elderly, postpartum or anemia patients, if the intestinal dryness due to blood deficiency does not moisturize the large intestine, it will cause constipation, and anal fissure will occur again after going to the toilet.
4) Stagnation of Qi and Blood Stasis: Emotional disorders, liver failure and diarrhea for a long time, liver depression and spleen suppression, spleen transfer negligence, large intestine flow is not good, long-term dryness and knots, struggling to damage the anus and form anal fissure.
It can be seen from the above pathogenesis that traditional Chinese medicine believes that constipation caused by various reasons makes it difficult for patients to defecate and struggle in the toilet. Damage to the anal canal is the main cause of anal fissure. In addition, inflammatory irritation, such as anal itching, anal fistula, and hemorrhoids And so on can cause anal fissure, postpartum anal canal or perineum damage and other traumas are also one of the causes of anal fissure.
1.3.3 Diagnosis of anal fissure in modern Chinese medicine
Pain is the main symptom of anal fissure. The pain of a typical anal fissure is characterized by periodic pain (pictured),
Pain during defecation Sphincter contraction pain
That is, during defecation, the stool stimulates the slit and rubs the nerve endings on the ulcer surface, causing paroxysmal burning or tear-like pain, which lasts for a few minutes to reduce or disappear. This is called the pain intermittent period, which usually lasts about five minutes and does not exceed ten. Minutes, then the anal sphincter continues to spasm and contract, and the pain worsens again, even more severe than during defecation. It is called a painful episode, which can last for several hours to more than ten hours, or even one day. Sphincter fatigue and relaxation. When I defecate again, periodic pain occurs again. In severe cases, even coughing and sneezing can induce pain in the anus and radiate to the perineum and lower limbs. The degree and duration of pain in anal fissures vary from person to person, depending on the depth and extent of the cleft. Generally it is severe, and even shock occurs, causing frequent urination, urinary incontinence, impotence and other phenomena.
Bleeding during defecation is caused by fecal damage to the small blood vessels in the wound. Generally, the amount of bleeding is not much, the bleeding is irregular, and sometimes no. If the bleeding is mostly dripping, the toilet paper is bloody or there is blood attached to the surface of the stool, the amount of bleeding is generally closely related to the severity of the anal fissure infection and the depth of the ulcer surface.
Most of them are rectal constipation. Patients with anal fissure are afraid of severe pain during defecation. They often delay defecation time and reduce the frequency of defecation. As a result, the feces stay in the intestinal cavity for a longer time and the water is completely absorbed, which makes the feces more dry and hard. It will deepen the crack and make the pain more intense. The result is a vicious circle of severe pain caused by anal fissure → fear of pain without defecation → dry and hard stool → greater wound damage during defecation → more severe pain of anal fissure, which affects the healing of anal fissure. It also
It is the cause of chronic anal fissure. Because of the fear of dry and hard stools, patients often take laxatives for a long time, which is prone to stubborn drug-dependent constipation.
(4) Anal itching
Due to the irritation of anal fissure secretions to the perianal skin, the formation of chronic eczema can cause anal itching. In addition, anal sinusitis, anal papillitis, or subcutaneous fistula caused by anal fissure can also stimulate the anal glands, increase the secretion of the glands, make the perianal moist and unclean, and cause itching. The patient feels that the anus is wet and uncomfortable, and the underwear is easily contaminated.
(5) Systemic symptoms
Severe pain can affect the patient's rest, increase the mental burden, cause abnormal excitement, insomnia, anal neurosis and other nervous system changes. Due to fear of pain, the patient's diet will decrease, and it will cause mild anemia or malnutrition and gastrointestinal dysfunction in the long term. Women can also cause irregular menstruation, pain in the lumbar and sacrum, fever, swelling and pain, and bleeding during anal fissure infection.
In order to avoid pain, the examination of anal fissure should be based on inspection. The patient takes the knee and chest position and asks the patient to relax the anus. The doctor gently separates the anal margin to both sides with two thumbs to observe whether there is a crack in the anal canal. Fresh anal fissures are mostly linear or fusiform ulcers. The wounds are shallow and only invade the subcutaneous tissues. The wound edges are neat and elastic. The wounds are crimson or bright red. There is no anal papilla hypertrophy and sentinel hemorrhoids. Old anal fissures are mostly fusiform, gray-white in color, deep in the bottom, and the edges of the crack are irregular and hard, and there are often raised skin tags, called sentinel hemorrhoids. Palpation and anoscopy are generally not used because they are easy to cause pain in the patient. If necessary, 1% lidocaine or 3% caine can be applied to the surface of the anal fissure, and the inspection will be performed after 5 minutes. During the anal examination, the enlarged anal papilla above the cleft and the inflamed anal sinus with a deep depression can be palpated. Complications such as induration of the anus and repeated subcutaneous ducts can also be seen.
188.8.131.52 Classification of anal fissures
The classification of anorectal diseases in Chinese medicine began in 1975 and has gone through the following four stages:
(1) The second-stage classification formulated by the National Anorectal Academic Conference in 1975
① Early (fresh) anal fissure: The fissure is fresh, no chronic ulcer has been formed, and the pain is mild.
②Old anal fissure: chronic ulcer formation, accompanied by anal cryptitis or anal papilla hypertrophy, and periodic pain.
(2) The three-phase classification formulated by the Yinchuan Conference in 1978
Stage I: Superficial laceration of the anal canal epithelium without ulcers and complications.
Stage II: Full-thickness dehiscence of the anal canal and ulcer formation without complications.
Stage III: Same as stage II, with complications.
(3) Guilin's first anal fissure meeting in 1992 formulated standards and divided anal fissures into four phases
Stage I: The breach is shallow, fresh, mainly bleeding, and self-healing.
Stage II: The formation of split ulcers, shallow and rosy, without complications.
Stage III: split ulcer, deep and gray, sphincter muscles exposed, less bleeding, mainly periodic anal pain, with complications.
Stage IV: On the basis of the third stage, the ulcer is deepened, the edge is protruding, and the symptoms are many and severe.
(4) Standards for the diagnosis and efficacy of Chinese medicine diseases issued by the State Administration of Traditional Chinese Medicine in 1994
1) Pain is obvious during defecation, and the pain can be aggravated after defecation, often constipation and a small amount of blood in the stool. It usually occurs in the middle of the anus.
2) The skin of the anal canal has a superficial longitudinal fissure, neat wound margins, fresh base, red color, obvious tenderness, and elastic wound surface. It is more common in stage I anal fissure.
3) There is a history of recurrent attacks. Irregular wound margins, thickening, poor elasticity, purple-red ulcer base or purulent discharge. It is more common in stage II anal fissure.
4) The edge of the ulcer is hard, the base color is purplish red, and there is purulent discharge. Anal papilla hypertrophy near the anal sinus at the upper end; sentinel hemorrhoids or subcutaneous fistula at the lower end of the wound margin. More common in stage III anal fissures.
In 1995, the three-phase classification of anal fissures was proposed in the criteria for diagnosis and efficacy of various diseases in Chinese medicine.
First-stage anal fissure: The skin of the anal canal is superficial and longitudinally fissure, the wound edge is neat and fresh, tenderness is obvious, and the wound surface is full of elasticity.
Second-stage anal fissure: a history of recurrent attacks. Irregular wound margins, thickening, poor elasticity, purple-red ulcer base or purulent discharge.
Three-stage anal fissure: The ulcer has hard edges, purplish-red basal color, and purulent discharge. Anal papilla hypertrophy near the anal sinus at the upper end; split hemorrhoids at the lower end of the wound margin.
I believe that the purpose of classification of anal fissures is to summarize the pathological changes and clinical manifestations of anal fissures at different stages, so as to better serve the clinic. If the treatment of anal fissure is divided into conservative treatment and surgical treatment in general, I think the second-stage classification developed by the National Anorectal Conference in 1975 is more practical.
1.3.4 TCM treatment of anal fissure
184.108.40.206 Syndrome Differentiation and Treatment
At present, the diagnosis and treatment of anal fissure is not unified. In most textbooks such as "Traditional Chinese Medicine Surgery", anal fissures are divided into three types: Pain, dripping or bleeding on toilet paper. The color of the mouth is red, the abdomen is full, yellowish, the tongue is reddish, and the pulse is chord. The treatment is suitable for clearing heat and moistening the bowel. Recipe with Liangxue Dihuang Decoction and Spleen Yoemaren Pills. (2) Yin deficiency and body loss: dry stools, one line for a few days, pain during stool, dripping blood, deep red mouth, dry mouth and throat, five upset fever. Red tongue, little or no coating, thin pulse. It is appropriate to nourish yin, clear heat and moisturize the intestines. Recipe with intestine soup. (3) Qi stagnation and blood stasis: The anal tingling is obvious, especially after defecation, the anus is tightened, and the color of the crack is dark and purple. The tongue is purple and dark, and the pulse is stringy or astringent. It is suitable for regulating qi and promoting blood circulation, moistening the intestines and laxative. Recipe with six mill soup with peach kernel, red spoon and so on. In the China Anorectology published by China Science and Technology Press in February 2002, the editor-in-chief of Ren Jianguo, anal fissures are divided into four types: (1) blood heat, dry intestines, constipation, severe pain in the anus during defecation, and even facial Red sweating, blood dripping or staining on toilet paper, bright red color, sometimes upset and irritable, fullness of abdomen, short red urine, dry mouth and throat, red tongue, dry yellow fur, stringy pulse. It is suitable to cool blood to moisturize dryness, stop bleeding and relieve pain, and add and subtract Liangxue Dihuang Decoction. (2) Damp-heat accumulation, poor stool, pain in the anus, blood in the stool, swelling of the anus, mucus from time to time, damp perianal, tired body, and bitter mouth. The tongue coating is yellow and greasy, and the pulse is several. It is suitable for clearing heat and removing dampness and laxative, and the prescription is to add or subtract 薆 dampness and scalding. (3) Qi stagnation and blood stasis, fissure hemorrhoids outside the anus, anal tingling or swelling pain, especially after defecation, anus tightening. The tongue is red and slightly purple, and the pulse is stringy or astringent. It is suitable to promote blood circulation to remove blood stasis, promote qi to relieve pain, and use Huoxue Sanyu Decoction as a prescription. (4) Blood deficiency, dry intestines, dry stools, pain and bleeding during stool, dizziness and palpitations, dull complexion, dry skin, pale tongue and little moss, weak pulse. It is suitable to nourish blood and nourish yin, moisten the intestines and lax, and use the addition and subtraction of Runchang pills.
I believe that the classification of anal fissures is important, but in the absence of a unified standard, as long as we distinguish the deficiency and reality of the disease for a long time, and then take the medicine according to the patient's physique, we will definitely gain something.
220.127.116.11 Special prescription and special medicine research
18.104.22.168 Other traditional Chinese medicine
(1) Diet therapy
Eat more vegetables and fruits, drink more water, and increase foods that contain more fiber to keep your stools smooth, make notes soft, and lessen the irritation to cracks.
(2) Regular defecation
The defecation time that meets the physiological requirements is to get up in the morning or after a meal. Wake up in the morning and defecate after meals, without increasing abdominal pressure, and smoothly discharge the stool
(3) Fumigation and bath therapy
It is suitable for anal fissure caused by various reasons, with the purpose of promoting blood circulation, removing blood stasis, reducing swelling and pain, and constricting the mouth. The traditional Chinese medicine sitz bath has a long history in treating anal fissures. For example, there is a record in the "Jin Jian of Medical Zong · The Keys of Surgical Mind Method" that the sitz bath is used to treat anal diseases with Qu Du Tang, which is still widely used. In recent years, there have also been reports on the treatment of anal fissure with sitz bath, such as Liu Yan, Yang Mai, Shang Xiaoli, Ding Shiyu, etc. 22 Treated 36 cases of anal fissure with cracking healing decoction, 12 were cured, 13 were effective, and 10 were effective. , 1 person is ineffective, the total effective rate is 97.2%, the composition of the medicine is: Scutellaria baicalensis 20g, Cangzhu 20g, Alum 15g, Gallnut 10g, Safflower 10g, Frankincense 10g, Sanyu 15g, Sophora japonica 15g, Forsythia 20g, Purple Grass l0g, Glauber's salt 20g. The usage is that the above medicine is placed in a porcelain basin with 5000ml of water and decocted for 30 minutes. The patient is instructed to sit on the basin while it is hot to smoke and wash the affected area, taking care to prevent scalding. The anus must be immersed in the human medicinal solution for about 40 minutes each time, 1 dose a day, and fumigation and washing once in the morning and evening, 7 days as a course of treatment. Lu Rong, Sun Jianhua, et al. 23 used Pufan lotion to treat anal pain. The medicine consisted of 30g each of dandelion, raw gardenia, barbata, gall, Glauber's salt, and alum. For severe pain, add frankincense and 30g each of myrrh. The method of use is to add 1500~2000ml of water to the upper medicine, soak for 30 minutes, and fry on a high fire. After boiling, switch to a slow fire for 5 minutes, smoke first, and then sit in a bath for 15 to 20 minutes after the water temperature drops, 1 to 2 times a day, 5. ~7d is a course of treatment. Treatment results: Among 120 cases, 103 cases were relieved after 1 course of treatment, 15 cases were relieved after 2 courses, and 2 cases were ineffective. The total effective rate is 98%. Li Runshan 24 uses "Zhicra Decoction" (15 grams each of frankincense, myrrh, peach kernel, safflower, loofah, wormwood, and chinensis root bark) with decoction and bathing, and the cure rate is 97.6%. Hu Haihua treated with a bathing recipe (20 grams of gallnut, 30 grams of Glauber's salt, 6 grams of Sichuan pepper, 15 grams of Qinwu, 15 grams of Cnidium, 12 grams of Sophora japonica, 12 grams of horse teeth, 12 grams of Nepeta), and the effect was also good . Zhao Meiyu 25 used self-made traditional Chinese medicine fumigation and washing to treat 31 cases of anal fissure with a recovery rate of 93.5%, which proved that the treatment of liver fissure with traditional Chinese medicine fumigation and washing has the effects of reducing swelling, activating blood and relieving pain, clearing heat and detoxifying. The composition of the medicine is 2kg of Glauber's salt, 2kg of moonstone, 1.5kg of alum, 5kg of lychee grass, 2kg of Shengchuan bird, and 1kg of safflower. The above-mentioned medicines are crushed into coarse powder, sieved, thoroughly mixed, and packed into 200 bags of non-woven bags, each weighing 65g. The treatment method is to take a bidet and place a sterilized bidet on it. Take 1 pack of the prepared medicine bag and put it in the bidet. Pour 500m of boiling water into the basin. 1. Let the patient sit on the chair. The distance between the anus and the liquid level is about 20cm. Then the water is extremely hot. Good conductor, strong heat and strong penetrating power. This principle fumigates the anus. When the water temperature gradually drops to 50℃-60℃, wipe the affected area gently with sterile gauze dipped in liquid medicine. When the water temperature reaches 40℃, ask the patient to soak the medicine In the liquid, until the medicine is cool. Fumigation and washing 15min-30min each time, once in the morning and once in the evening.
(4) Medication therapy
It is suitable for anal fissure caused by various reasons. Commonly used patent medicines such as Jiuhua ointment and Sihuang ointment, etc., apply ointment to the lesion to clear away heat, detoxify, stop bleeding and relieve pain. For fresh anal fissures, use Mayinglong hemorrhoid ointment and erythromycin ointment to rub externally; indomethacin suppository and diclofenac sodium suppository to the anus to relieve inflammation and pain. Liu Weidong, Liu Xingkui 26 reported that 50 cases of anal fissure were treated with Zhuhuang ointment, 32 cases were cured within 1 week (symptoms disappeared and wounds healed), accounting for 64%; 12 cases were cured after 2 weeks of medication, accounting for 24%; improved (symptoms alleviated, wounds healed) Partial healing) 6 cases, accounting for 12%. The total effective rate is 100%. The composition and preparation method of the medicine: 25g each of bezoar, dragon's blood, bletilla striata, comfrey, and pearl. Dry the medicine, crush it through a 150-mesh sieve, add 15g borneol, and mix well, and add the melted medical vanilla. Bo Lin, prepared into an ointment according to the ratio of Chinese medicine and Vaseline 1:4, bottled and sealed for later use. The method of use is that the patient takes a bath with warm salt water for 10 minutes after each defecation, and then changes the dressing with Zhuhuang ointment. Each time the dressing is changed, the size of the cleft is evenly coated on the wound surface, the outer cover is sterilized and the dressing is fixed with tape.Zheng Xiangyang 27 reported that 120 cases of anal fissure were treated with "Crack Yusan", 100 cases were cured, and 20 cases were markedly effective. The pharmaceutical composition is: 30 grams of silkworm eggs, 20 grams of Coptis, 1 gram of borneol, and 0.5 grams of grinding incense. The processing method is that when the silkworm moth lays its eggs, the silkworm moth is placed on the prepared straw paper to lay its eggs, and then the silkworm eggs and the straw paper are satin-coated to gather dust, and then ground after cooling. Coptis is sieved with very fine powder, and the rest is fine powder. Mix all the medicines and mix them into a paste with an appropriate amount of clear oil for later use. Take an appropriate amount and apply to the affected area. Qian Zhongxiu 28 is dried with 200 grams of dried alum, 80 grams of borneol, 80 grams of coptis, and 60 grams of gallnut, grind the powder through a fine sieve, add appropriate amount of sesame oil, and heat to make an ointment for external use. 1 to 2 days, apply topically to the anal fissure wound once for 1-5 times. 200 cases of anal fissure were treated, 166 cases were cured, and 34 cases were markedly effective. Wang Runcheng 29 used wax egg butter to treat anal fissures, using 3 egg yolks, 3 grams of beeswax, and 3 mussels. Boil the eggs, take the yolk to refine the oil to remove residues, remove the shells of the mussels to remove the meat, combine the eggs and butter to grind them into mud, then heat the beeswax into a pot to turn into a liquid, combine the mussels mud and egg butter and mix together. After use, apply externally to the affected area. Huangjiechao 30, etc. Use compound coptis solution to treat anal fissures. The specific method is: 10 grams of coptis, 1 gram of borneol, and 200ml of distilled water. Crush the coptis, put it in a flask or pot with 200ml of distilled water, boil for 30 minutes on a slow fire, filter with gauze, and filtrate. Add borneol, stir and filter once again with gauze to obtain 100ml of filtrate, which will be used after sterilization. When using it, dip a cotton swab into the liquid medicine, apply the medicine to the anal fissure wound like a plum needle prick method, 2-3 times a day, and the effect will be seen within a few days. Li Kezhen 31 treated 100 cases of anal fissure with topical talc white and powder, 94 cases were cured and 6 cases improved. The method is to use half of the talcum powder, white powder and half powder. Use cotton or gauze to apply the powder to the anal fissure. Then massage the Changqiang acupoint several times with your hands. It is advisable to feel fever around the anus once a day. Oral ginseng spleen pill and maren pill, one pill each morning and evening
Li Qigeng 32 is made with 15 grams of dragon's blood, 15 grams of gallnut, 10 grams of cinnabar, 50 grams of calamine, 10 grams of satin keel, 100 grams of satin plaster, 10 grams of borneol, 30 grams of propolis, 400 grams of petroleum jelly, and appropriate amount of sesame oil Anal fissure cream is effective in treating anal fissure.
Yan Shuwen 33 reported that Sanhuang ointment was used to treat anal fissures, using 10 grams each of Coptis, rhubarb, and realgar, and 2 grams of borneol, a total of fine powder, dried in vinegar. When used, apply pig bile ointment, or add a proper amount of honey to make a suppository, stuff it in the anus, twice a day, usually take effect in 3-5 days, and heal in about 1 week.
Guan Jiasheng et al. 34 used Yuchi ointment to treat 51 cases of simple anal fissure. The basic drug composition is elephant skin (refined powder) 60g white wax 60g self-zhi 15g angelica tail 60g light powder 5g (additional or subtraction as appropriate) Corydalis 30g dragon's blood 20g safflower 20g comfrey 6g, appropriate amount of sesame oil. Among the 51 cases of treatment, 38 were cured, 11 were markedly effective, and 2 were effective. The total effective rate was 100%.
(5) Acupuncture and Tuina Therapy
This method is suitable for people with severe pain in anal fissures. By stimulating the meridians and acupoints, they can dredge the meridians, regulate qi and blood, and achieve the purpose of pain relief and bleeding and promoting healing. Common acupoints include Changqiang, Baihuan and Chengshan. According to clinical reports, Zhang Lijuan 35 acupuncture Tianshu, Dachangshu, Zusanli, Sanyinjiao, Changqiang, Chengshan and other points to treat 45 cases of anal fissure, 38 cases were cured, 6 cases improved, and 1 case was ineffective. It is believed that Tianshu and Dachangshu are the Shumu points of the large intestine, which can dredge the qi of the large intestine; Zusanli is the combined point of the stomach meridian, which regulates the spleen and stomach, and helps the large intestine to excrete dross; Sanyinjiao is the Jiaohe point of the Zusanyin meridian, which benefits yin Producing body fluid, increasing water and running boat, Changqiang is the collateral point of the governor channel, located beside the anus. Acupuncture at this point can relieve internal sphincter spasm; Chengshan is the main point for the treatment of anal diseases, which can relieve anal pain and regulate anal function Has an important role. Xing Meisong used electro-acupuncture for the treatment of Dachangshu, Kongzu, and Shangjuxu points. The G6805 therapeutic apparatus was energized for 20-30 minutes at a frequency of 100-120 times per minute, once a day. 52 cases were treated, 36 cases were cured, 9 cases were markedly effective, 4 cases were effective, and 3 cases were ineffective.
Wang's 36 et al. took Changqiang and Shuangchengshan to treat 124 cases of this disease. The needle Changqiang was inserted in the direction of the tailbone. Chengshan straight puncture. The needle was kept for 5-10 minutes. During the needle retention period, the needle was stimulated 1 or 2 times. The result was 105. For example, 16 cases improved. 3 cases failed. The total effective rate was 97.3%. Jin's et al. 37 used massage therapy to treat 42 cases of anal fissure. First press the Changqiang point for a few seconds. Then take the Changqiang point along the perineal area and make double pairs along the perineum. Push the thumb repeatedly. After getting better, instruct the patient to massage with one hand on his own. Each push is 5-10 minutes. The result is healed after 7-43 days. After healing, 36 cases had no recurrence within 2.5 years. Relapsed patients were cured by massage. Chen's 38 used a small needle knife to treat 208 cases of anal fissure. The small needle knife was used to insert the needle vertically and slowly from the left side of the anal canal 1 cm away from the anal edge to between the tooth line and the internal sphincter. The needle was inserted longitudinally and peeled laterally. Cut off the internal sphincter.Patients with sentinel hemorrhoids and anal papilla hypertrophy should be trimmed. Results The 176 cases followed up were cured once without recurrence. Ye's 39 takes catgut and embeds it at Changqiang point. Apply compound self-contained gauze on the incision and anal fissure wound: if it is accompanied by split hemorrhoids and anal papilla hypertrophy, it can be removed or electrocautery. A total of 62 cases were treated. 58 cases were cured after one implantation, 3 cases improved, and 1 case failed. Jiang’s 40 and others also took thread-embedding at Changqiang point. 32 cases of this disease were treated. 29 cases were cured. Among them, 26 cases were cured once. 3 cases were cured twice: 3 cases improved. The cure rate was 90.6%:
(6) Needling therapy
This method is a traditional Chinese medicine treatment. Generally, the waist and back and gingival intersect are more choices. Anal fissure patients often have positive reaction points in these areas. Such as local tender points or allergies, or induration, papules, etc. It is not only suitable for anal fissures, but also for inflammatory external hemorrhoids and internal hemorrhoids bleeding. Acupuncture therapy has a good clinical effect in the treatment of anal fissures. However, the depth and size of the site should be grasped carefully, and attention should be paid to avoid blood vessels and nerves and prevent infection. For example, Li's 41, etc. take Baliao, Yaoshu, and Changqiang. Use self-made front needles to break the skin 0.5 cm horizontally at the meridian circulation part. Then use front needles to pick down 0.5-1.0 along the mouth. The depth of about cm. Cut the subcutaneous fat. Pick out the milky white fiber-like substance: 6 cases of anal fissure treated with acupuncture at Changqiang Point. Good results were received. Cao et al. 42 selected bilateral Dachangshu or nearby obvious tender points for treatment. A total of 9 cases of anal fissure were treated. The curative effect was satisfactory. Chen et al. 43 were based on the experience of local old Chinese doctors. Below the 7th thoracic vertebra, the axilla on both sides of the sacrum Look for hemorrhoids in the range between the posterior lines. When there are many hemorrhoids, take the place close to the spine. The lower the better: If there is no hemorrhoids, you can find an obvious pain point or choose Dachangshu acupoint for treatment. It is believed that the anal fissure, The effect of internal hemorrhoids and inflammatory external hemorrhoids is better. Zeng’s 44 is placed on the back of the lumbar triangle area. Try to be as close as possible to the positive point between the Governor Vessel and the Vessel. After the selection, adhere to abdominal breathing exercises: those with inflammation or stool Can be used in conjunction with traditional Chinese medicine. Treatment of anal fissure combined with hemorrhoids has received better results. The positive reaction point of Diao's 45 at the Gingjiao point. Use a scalpel to quickly remove it: then pick and treat the tenderness at Dachangshu or nearby. Cooperate with local anal fissures to rub egg butter. It is believed to have a better effect on anal fissure, internal hemorrhoids, and external hemorrhoids. Song 46 used upper lip frenulum to treat 20 cases of anal fissure. At the same time, antibiotics were taken to prevent infection. Results 15 cases were cured once and 5 cases were cured twice.
(7) Qigong therapy
Sun Ronggen's treatment of anal fissure with the method of transferring the anus to the abdomen received satisfactory results. This exercise consists of two steps. The first step is the turning of the abdomen. After entering the stillness, put your hands on your hips, the tiger’s mouth down, your thumbs on the front waist, the head and lower limbs are basically still, so that the waist turns like a shuttle, right and then back On the left, with even breathing, rotate 100 times each. The second step of the anal movement method requires uniform and slender breathing. When inhaling, the mental internal air gradually rises from the anus to Baihui, while slowly lifting the anus; when exhaling, the mental internal Qi gradually decreases from Baihui to the anus. At the same time, the anus slowly descends to the bottom, so it rises and falls no less than 30 times.
Traditional Chinese medicine advocates the differentiation and treatment of anal fissure, which can be divided into four types: blood heat and intestinal dryness, blood deficiency intestine dryness, yin deficiency and body fluid deficiency, and qi stagnation and blood stasis. The treatment is based on the principle of holistic view, using oral Chinese medicine, topical application, fumigation, and acupuncture. Tuina, surgical treatment and other methods have irreplaceable advantages of Western medicine. However, the understanding of local anatomy, physiology and pathology of the anus, as well as advanced surgical and scientific research techniques, Chinese medicine is slightly inadequate compared to Western medicine. Hope that with the development of the times , Chinese and Western medicine can truly be combined to benefit mankind.
2 Western medicine's understanding of anal fissure
2.1 The anatomical basis of anal fissure
The anus is the opening at the end of the digestive tract, that is, the outer opening of the anal canal. It is located in the midline of the buttocks. It is in the anal triangle. The anus is elliptical when closed in men, and it is round star-shaped in women. A longitudinal groove is formed between the tip of the tailbone, the gluteal groove. This groove is deep and easy to be wet and infected. Perianal abscess, apocrine inflammation, anal itching, condyloma acuminatum and anal fissure are prone to occur. The gluteal groove is shallow, not damp, and not easily infected. The anal triangle and the perineal triangle (that is, the urogenital triangle) are collectively called the perineum. The superficial part of the external sphincter is connected to the perineal body muscle in the front, and then to the midline of the scrotum. The superficial part of the external sphincter is borrowed backward to form two bundles, which are attached to the anal caudal ligament after crossing the anal canal. Because of the front-to-back connection, the superficial part of the external sphincter is fixed to the surgical anal canal in a fusiform shape. The perineal body muscles and superficial perineal fascia are wrongly removed during the operation, and the anus will shift backward. Such as the posterior rectal space abscess or anal fistula, surgery is easy to damage the levator ani muscle. Such as an abscess in the posterior anal canal, it is easy to damage the anal caudal ligament during surgery. From the anal margin to the ischial tuberosity, it is called the perianal. The perianal skin is closely connected to the superficial subcutaneous fascia. The perianal skin is thicker than other skins and has pigmentation.When the underside of the external sphincter skin and the anal corrugated muscle contract, radial folds form outward from the anal margin. Therefore, during perianal surgery, radial incisions should be selected as much as possible to avoid damage to corrugated muscle fibers. There are hair follicles, sweat glands, and sebaceous glands in the perianal subcutaneous tissue. If the sassafras injury or the gland duct is blocked by secretions, it can cause perianal subcutaneous abscess or furuncle, and occasionally apocrine inflammation. Deep gluteal grooves are prone to anal fissures and hemorrhoids. There are many perianal secretions that irritate the skin and can cause anal skin diseases such as anal itching, anal eczema, and anal condyloma. There is no deep fascia in the anus, only superficial fascia and cellulite. It is divided into many lobules and fat tissues, which are directly connected to the fat tissue in the ischial anal space. There is little fat in the front of the anus, and it is completely absent from the scrotum. In superficial fascia purulent infection, it spreads widely and is prone to acute necrotizing fasciitis. In addition, because of the fibrous septum between the fat lobules, when an anal fistula is left, the behavior is often curved. During the operation, the movement of the fistula, the presence or absence of branches and dead spaces should be explored. There are many subcutaneous venous plexuses in the anus, which are prone to form varicose external hemorrhoids, and then thrombotic external hemorrhoids.
2.1.2 Anal Canal Anatomy
In the literature, there are two definitions of the anal canal: anatomy or embryology. The anal canal is short, from the outer edge of the anus to the dentate line, about 2cm, which is the ectoderm developed from the protoanal in the embryonic stage. The front wall is shorter than the back wall. The skin of the anal canal is special, the surface is smooth and white or light red, there are no sweat glands, sebaceous glands and hair follicles, it is not easy to be infected, and the structure of the mouth is the same. The skin of the anal canal should be preserved during the operation. Excessive resection may result in narrowing of the anal canal and difficulty in defecation. Surgery anal canal or functional anal canal, the earliest defined by shafik, extends from the outer edge of the anus to the anorectal ring, approximately 4cm in the height of the prostate in men, and flush with the perineal body in women. Surgical anal canal consists of two different tissue structures, which are purely artificially extended anal canals, which play an important role in guiding clinical practice. The long axis of the surgical anal canal is 4 cm pointing to the umbilicus, which is the part that forms a right angle to the anus. Therefore, when an anoscope is used, it is required to insert 4 cm into the umbilicus first, then adjust the direction and insert 4 cm backward. During anoscopy, in order to prevent the insertion of the lens from causing perforation, the standard anoscope is set to be 8cm just outside the peritoneum. A section of the rectum from the inner edge of the levator ani muscle to the dentate line is called the rectal neck. The junction between the rectal neck and the rectum is called the inner mouth of the rectal neck, also known as the rectal stenosis. Because the rectal neck is located below the pelvic diaphragm, it is also called perineal rectum. During rectal obstruction and anus preservation surgery, the rectal neck must be preserved and the rectal angle reconstructed to prevent fecal incontinence. The dentinal line is the boundary line between the rectum and the anal canal. It consists of the anal flap and the lower end of the anal column. Due to the contraction of the sphincter, 6-10 longitudinal strip folds appear in the mucosa above the dentate line, which is about 1-2cm in length, which is called the rectal column. This column can disappear when the anal canal is dilated. The lower segments of the rectal column are connected by a semilunar mucosal fold, which is called anal flap. The rectal mucosa between the anal valve and the rectal column forms many small pits, called anal sinuses. The sinus mouth is upward, about 3-5cm deep, and there is an anal gland opening at the bottom. There are 2-8 triangular papillary protrusions under the anal flap, called anal papilla. The anal gland has a tubular part under the mucosa called the anal gland duct. 2/3 of the anal gland extends downwards and outwards to the internal sphincter. A few can pass through the muscle to the joint longitudinal muscle layer, and a few can enter the external sphincter, even the ischial rectum Nest gap. Most scholars believe that the anal gland is the source of all perianal diseases.
2.1.3. Anatomical landmarks of the anal canal
There are mainly four lines and three zones
(1) The four lines are the four anatomical lines of the surgical anal canal, which have important clinical significance
Anal canal skin line: It is the dividing line between the anal canal skin and the anal skin, namely the anal margin. Taking the depth of pigment between the perianal skin and the outer mouth of the anal canal as the boundary, the perianal skin is more pigmented, brownish red, the anal canal skin is lighter, pink, and the perianal skin is loose, with sweat glands, sebaceous glands and anal hair , Such as more surgical resection, does not cause stenosis. The skin of the anal canal is tight, without sweat glands, sebaceous glands, and anal hair. If more surgically removed, it is easy to cause stricture. The anal skin heals faster, and the anal canal skin heals more slowly.
Anal white line: Hilton's white line, which is the boundary line between the lower edge of the internal sphincter muscle and the lower part of the external sphincter skin. It is called because the blood vessels are less white. During digital examination, you can feel a circular groove, also known as the intersphincter groove. There are joint longitudinal muscle fibers attached to the epithelium below the anal comb in the groove. The width of the groove is about 0.5cm, and the terminal fibers of the combined longitudinal muscle extend from this groove to the inner and outer sphincter, so that the perianal muscles and perianal skin are closely connected to fix the anal canal and assist defecation. Such as surgery and other causes of injury combined with longitudinal muscle fibers, it will cause anal contraction and diastolic dysfunction, and difficulty in defecation. At the end of the anal fissure, an incision is made from the intermuscular groove outward, and internal sphincter lysis is performed. The internal sphincter is selected and cut, or a section of the internal sphincter is excised. It is strictly forbidden to use silk thread to stop bleeding, causing anal discomfort. Avoid ligating The foreign body remains. In anal fissure lateral resection, this groove is often used as a sign to distinguish the internal and external sphincter.
Tooth line: is the dividing line of the anal canal skin and rectal mucosa. Also known as comb line. It is the serrated line connecting the anal papilla and the free edge of the anal valve, so it is called the tooth line. It is the place where the endoderm of the primitive rectum and the ectoderm of the primitive anus meet in the embryonic stage. The upper and lower tissue structures are different. More than 85% of anorectal diseases occur near this place. Above the tooth line is the rectum, and its epithelium is a single layer of cubic or columnar digestive tract mucosal epithelium; below the tooth line is the anus, and its epithelium is transitional flat or stratified flat epithelium. The nerves on the tooth line are autonomic nerves and there is no obvious pain. The nerves under the tooth line are spinal nerves, which are sensitive. Therefore, anal fissures and external hemorrhoids are very painful, and there are painful areas during surgery. The blood vessel above the dentate line is the upper rectal blood vessel, and its vein is connected to the portal venous system; the blood vessel under the dentate line is the anal blood vessel, and its vein is the inferior vena cava system. The portal vein communicates with the body vein near the tooth line. Lymph above the tooth line flows upwards into the pelvic lymph nodes; the lymph below the tooth line flows downwards into the inguinal lymph nodes through the base of the thigh. Therefore, the tumor metastasizes, above the tooth line to the abdominal cavity, and below the tooth line to the root of the thigh. The tooth line is also the defecation reflex induction zone. The dentate line is distributed with highly specialized sensory nerve terminal tissue. When the stool reaches the anus from the rectum, the nerve terminal receptors in the dentate line area are stimulated, which will cause the internal and external sphincter to relax and the levator anus muscles contract to make the anus. The tube opens and the stool is discharged. If the dental floss is removed during the operation, the bowel reflex will be weakened and constipation or sensory incontinence will occur.
Anal straight line: the anorectal line, also known as herrmannslinc line, is located at the inner mouth of the rectum neck, at the level of the anorectal ring, at the stenosis of the anal column, is the dividing line between the surgical anal canal and the rectum, and is the upper edge of the internal sphincter, combined The upper end of the longitudinal muscle is attached to the upper boundary of the rectal neck and is also the attachment point of the levator ani muscle. Digital rectal examination is a palpable narrow surgical anal canal where the upper end of the anus is straight.
(2) Three belts
Column zone: located in the circular area from the horizontal line of the surgical anorectal canal to the dentate line. During the period, there is an anal column and the mucosal surface is a single layer of columnar epithelium. This zone is the location where internal hemorrhoids and rectal polyps occur.
Hemorrhoid belt: the hemorrhoid ring, also known as the comb belt. The position of the anus comb is the area from the tooth line to the white line of the anus. It is the area where varicose external hemorrhoids occur, called the hemorrhoid belt. Because the hemorrhoid band is contracted by the internal sphincter, a narrow ring is formed, which is the migration site of the mucous membrane and the skin, and the site of anal fissure.
Belt: the area from the white line of the anus to the edge of the anus. It is surrounded by the lower part of the external sphincter skin. The epidermis is stratified flat epithelium. It is the area where connective tissue external hemorrhoids occur. Clinically, inflammatory external hemorrhoids are often complicated. Of course, there are also varicose veins in this belt. External hemorrhoids, clinically often complicated by thrombotic external hemorrhoids.
2.14 Division of anorectal
(1) Taking the pelvic diaphragm as the boundary: Shafik calls the part above the pelvic diaphragm proper rectum. The part from the pelvic diaphragm to the tooth line is called the rectal neck, and the part below the tooth line is called the proper anal canal. Position the inner rectal neck at the junction of the proper rectum and the rectal neck, which is equivalent to the level of the anorectal ring at the upper end of the rectal column, and the outer opening of the proper anal canal is the anus.
(2) With the upper edge of the levator ani muscle attached to the rectum as the boundary, divide the rectal neck and rectal ampulla.
(3) With the lower mouth of the pelvis as the boundary, locate the junction of the rectum neck and the rectum.
(4) The boundary below the rectal perineal curve is the boundary between the surgical anal canal and the rectum.
2.1.5 Muscles around the anorectal canal
The anal canal is surrounded by the anal sphincter complex, which consists of two layers of muscles that overlap each other. The outer layer is the external analsphincter (EAS), which is skeletal muscle and voluntary muscle. The inner layer of the anal sphincter complex is the internal anal sphincter (IAS), which is the involuntary smooth muscle part of the anal sphincter complex.
1 Internal anal sphincter: The internal anal sphincter is a continuation of the circular muscle layer of the rectum. It is a smooth muscle and is pearly white. The upper boundary of the anal canal is level with the plane of the anorectal muscle ring, down to the intersphincteric groove, and encompasses the upper 2/3 of the anal canal. IAS muscle bundles are elliptical, and are arranged continuously overlapping in an imbricate shape. The upper fiber is inclined inward and downward, the middle part is gradually horizontal, and some fibers in the lower part are slightly inclined upward. The lower end of the IAS is the thickest, forming a clear ring-shaped free edge surrounded by elastic fibers that unite the longitudinal muscles. The width of IAS is 2.32±0.65cm, and its thickness is not consistent throughout the week, generally 0.54±0.38cm. IAS is hypertrophy in elderly and chronic constipation patients. According to measurement, the lower edge of the IAS is mostly below the plane of the tooth line, and the distance between the two is 0.79±0.0lcm. The IAS and the tooth line are equal to 2.5% of the tooth line generally located in the middle of the muscle Or the middle and lower 1/3 junction. The lower edge of IAS was 0.90 ± 0.01 cm above the anal edge, and no flush with the anal edge was found.
2 The external anal sphincter is divided into three parts: subcutaneous, superficial and deep. The lower part of the skin is the circular muscle bundle, located in the subcutaneous layer at the lower end of the anal canal, below the internal sphincter. The superficial part is an elliptical muscle bundle that starts from the tailbone, surrounds the anal canal forward, and ends at the central tendon of the perineum. The deep part is located above the superficial part and is a circular muscle bundle that merges with the puborectalis muscle. Its function is to close the anal canal at ordinary times, relax during defecation, and help defecation; close the anal canal immediately after defecation.
3 The levator ani muscle is a layer of muscle that forms the pelvic floor around the rectum. It is composed of the puborectalis muscle, pubococcygeus muscle and iliococcygeus muscle. It starts from the two side walls of the pelvis, and stops obliquely downwards on both sides of the lower rectal wall. It is funnel-shaped and plays an important role in supporting the internal organs of the pelvis, helping defecation, and sphincter the anal canal.
4 The combined longitudinal muscle is composed of 3 layers, the inner layer is the extension of the rectal longitudinal muscle, the middle layer is the levator sling, and the outer layer is the extension of the top ring of the external sphincter. The three layers form a central tendon below the inner sphincter, which divides many fibrous septa. Its function is to fix the anal canal and assist the defecation of the dilator muscle.
2.1.6 Anatomical discussion on the pathogenesis of anal fissure
1. Minor triangle: the superficial muscle bundle of the external sphincter is bifurcated in a Y" shape behind the anus. It forms the Minor triangle with the subcutaneous muscle bundle. The skin of the anal canal lacks muscle support. It is a weak area. Blaisdell in 1937 The anatomical arrangement of the external sphincter points out that the lower part of the skin lies horizontally in front of the third. It is like a grid. When a dry and hard fecal mass spans its front or excessive expansion of the anus, it is prone to posterior laceration and anal fissure. This is the Blaisdell gate theory. Histology confirmed that the base of anal fissure is not the subcutaneous part of the external sphincter. It is the internal sphincter. Less external sphincter is not the cause of anal fissure.
2. Anal flap: The anal flap is a half-moon-shaped fold between the lower end of the rectal column 6-12. Its free edge is upward. As early as 1908, Ball imagined that an anal fissure is the anal flap being torn down by dry and hard feces. It is an extended linear wound, but the anal fissure is usually below the tooth line. It is still far from the anal valve. No trace of the anal valve is seen. Therefore, this statement cannot be established.
3. The combo and combo belt: combo refers to the epithelium of the anal canal between the tooth line and the intersphincter groove. It is the normal structure of the anal canal. "栉膜带" (peeLen band) is a term put forward by Mile in 1919 as the etiology and pathology of anal fissure. At present, it is still widely quoted in Chinese literature on anal fissure. In fact, it was as early as the 1950s. It has been ascertained that the combo belt is the internal sphincter. Positive. As described by Mile, there is no "Clamella band" formed by the proliferation of fibrous tissue under the chlamydia. The sphincterotomy that he advocated is actually the internal sphincterotomy.
4. Anal Artery In 1989, KIosterhalfen et al. used cadaveric angiography to find the branches of the anal arteries on both sides of normal people. Only 15% had better anastomosis at the anal commissure, while 85% had no anastomosis. The density of small blood vessels at this place Lower than the anterior commissure and on both sides. Formation. Deficiency of blood vessels. The small branches from the anal artery passing through the internal sphincter interval and the muscle fibers enter the muscle in a vertical direction. It may be that the blood vessels are compressed by muscle spasmodic contraction. The ischemia phenomenon of the posterior commissure is aggravated. Lund (1999) Histological observation of the anus The distribution of blood vessels in the skin area of each quadrant and the internal sphincter area. It is found that the distance between the upper and lower sides of the tooth line is 1cm. The number of small arteries in the rear is significantly lower than the above-mentioned anatomical findings in other areas. It is proved by physiological tests and clinical trials Schouten (1994) A laser Doppler blood flow meter was used to detect the blood flow in the anal canal skin of 31 healthy adults. It was confirmed that the blood perfusion pressure in the posterior commissure area was significantly lower than that in other areas of the anal canal (pictured)
Skin blood perfusion pressure in the four quadrants of the anal canal
2.2 Discussion on the etiology of anal fissure
At present, the cause of anal fissure is unknown. Many scholars have put forward their own opinions based on their own clinical research and scientific experiments. The current theories mainly include the following:
1 Anatomical theory as mentioned above, due to the existence of the minor triangle and most of the levator ani muscles attached to both sides of the anal canal, the front and back of the anatomical basis with less front and back is not as strong as both sides, and it is easy to damage the anal canal. The lower part of the anal canal is the rectal angle. The back of the anal canal is under heavy stool pressure. The blood supply to the midline of the back of the anal canal is small and the elasticity is small. These are all factors that cause anal fissure, but this theory only explains the good anal fissure. The congenital conditions that occur in special parts have no explanation for the direct cause of the formation of anal fissure.
2 The theory of trauma. Some scholars believe that dry and thick fecal sassafras, women tear the anal canal during childbirth, rough anoscope operation, anal canal stenosis or wound infection and various anal traumas after anal surgery can all cause the anal canal to split. Once the fissure surface is infected, an ulcer that does not heal for a long time becomes an anal fissure.But this theory cannot explain why some anal fissures heal on their own while others become chronic. According to statistics, only one quarter of patients with anal fissure have a history of constipation. Some diarrhea is the cause of anal fissure. Hamanel (1977) investigated 772 patients with anal fissure and found that only 10% of them had difficulty in defecation (>3 d) before treatment, while 75% of patients had 1-3 bowel movements. It can be concluded that most patients with anal fissures are not caused by the so-called dry and hard feces tearing the skin. They are not conclusive evidence of anal fissures. The defect of this theory is that trauma is a link in the process of anal fissure, and it cannot summarize the cause of anal fissure.
3 Infection theory. In 1932, Rankin, Bargen and Buie believed that infections caused by acute and chronic anal sinusitis, anal papillary hypertrophy, internal hemorrhoids and polyps entered the anal glands through the ducts, and formed abscesses in the subcutaneous tissues of the anal ducts, and ulcers formed after ulceration. , Small superficial thrombosis, septic necrotizing phlebitis due to infection is the cause of anal fissure, but is it anal fissure caused by infection or a secondary infection of anal fissure? Can ulcers and anal fissures be equal, and why Only the back of the anal canal is prone to anal fissure, and some scholars hold different opinions and are still in dispute.
4 Theory of Internal Sphincter Spasm
In recent years, studies have found that the cause of anal fissure is due to insufficient blood flow in the middle of the posterior anal canal. The average arterial blood pressure of the terminal artery is 85mmHg. The internal anal sphincter spasm increases the resting pressure of the anal canal, often greater than 90mmHg, which compresses the blood vessels. Lead to ischemia, which prevents the gap from healing",
5 Residual epithelial infection said: In 1982, Shafik tried to explain from embryology why anal fissure is prone to chronic. He pointed out that during embryonic anal canal formation, the original anus and posterior intussusception form rectal anal sinus, which disappears after birth. If there is residual rectal sinus epithelium under the skin of anal fissure patient, it may be caused by skin Damage is exposed to infection. Because this kind of tissue is poorly differentiated, it is buried under the skin like "dead bone", preventing the wound from being difficult to heal. However, Dohrenbusch et al. (1986) repeated the observation of Shafik and found that the so-called residual epithelium of Shafik is actually anal gland tissue, so this hypothesis cannot be established. "
6 Anal narrow elementary school said that the skin of the anal canal is slow in its development, resulting in a narrow anal canal, which is easily damaged and becomes anal fissure. This can only explain the cause of the disease in some specific populations, and cannot explain the cause of most patients with normal development of anal fissure.
7 Developmental differences: Chinese scholar Niu Zhijun believes that some people have individual differences in the degree of development of the internal or external sphincter. The normal thickness ratio of the internal and external sphincter is generally 1:1.5, but sometimes the difference is very large, up to 1:3 or 1:5. The internal sphincter is very thin, and the external sphincter is particularly thick, accounting for 17.3%; the external sphincter is particularly thin and the internal sphincter is 2-3 times thicker than the former. Therefore, the internal sphincter or external sphincter thickens and muscle strength increases. Under pathological conditions, it is easy to cause the anal canal skin's strain capacity to decrease and laceration.
8 Impaction theory: Chinese scholar Chen Shaoming put forward the impaction theory based on personal research results through the study of historical evolution, hypothetical reasoning, and clinical verification. He believes that various impactions in the anorectal hinder defecation and cause excessive expansion of the anal canal during defecation. The anal canal is at the limit of dilatation, the skin of the anal canal is cracked, and the infected wound forms a fusiform ulcer after repeated expansion or tearing of the anal canal. Impaction factors can be internal hemorrhoids, rectal tumors, hypertrophic anal papillae, secreted fecal mass, etc. This theory integrates various theories and is easy to understand and guide clinical practice.
9. The relationship between age and anal fissure: In the young and middle-aged, in men, due to the increase in the causes of anorectal dysfunction, the anal canal skin is more likely to be damaged by biomechanical factors. Therefore, between 20-40 years old is the peak period of male anal fissures; women between 20-40 years old, in addition to the increase in the causes of anorectal dysfunction that are almost the same as men, there are also childbirth. Gas consumption and body fluid loss during childbirth are the main cause of postpartum constipation. Constipation is easy to find and cause anal fissure. Therefore, it is the reason why anal fissure is more common in women than men, and it occurs frequently between 20-40 years old. After a person reaches 50, the skin and sphincter of the anal canal and sphincter have different degrees of fatigue damage, so different degrees of creep, relaxation and lag have occurred. Therefore, the incidence of anal fissures decreased significantly after 50 years.
2.3 Physiology and pathology of anal fissure
2.3.1 Research on the physiology of anal fissures: At present, the main focus is on the pressure of the rectal and anal canal of patients. Northman and schuster47 performed balloon rectal sphincter pressure measurement on patients with anal fissure, and the resting pressure was 2 times higher than that of the control group. . After the rectum is expanded by the balloon, there is expected internal sphincter relaxation, but then there is a long-term contraction that is significantly higher than the initial baseline, which is called hyperstimulation. Therefore, they concluded that the sphincter spasm caused by this reflex stimulation is related to the onset of anal fissure. Gibbons and read48 used perfusion probes of different diameters to detect chronic anal fissures. Compared with the control group, regardless of the probe size, the resting pressure of all patients increased, and it was observed that this phenomenon was not only caused by spasm, but also the anal canal. Mucosal ischemia may be the cause of pain, and it is also where the anal fissure cannot heal itself.
2.3.2 Pathological study of anal fissure
There are three main aspects of the pathology of anal fissure
1. Tissue damage: Due to various impaction factors, the force on the posterior and anterior mass points of the anal canal is greater than the ultimate strength value of the tissue, so a skin crack in the anal canal occurs.
2. Degeneration and exudation: After anal canal skin laceration, it is affected by inflammatory factors and the crack becomes infected. The tissue cells undergo deterioration and exudation, spreading to the skin and subcutaneous tissue of the crack, forming a spindle-shaped ulcer. The inflammatory zone produces and releases biologically active substances such as kinins and prostaglandins, which can act as mediators of nociceptor activation and act on painful nerves to cause pain. The active substance produced also has the effect of spasm of vascular smooth muscle and internal sphincter. The external sphincter is a striated muscle, and its movement is controlled by nerves. Therefore, the contraction response of the internal and external sphincter muscles is directly proportional to the intensity of inflammatory mediator stimulation. The higher the frequency of stimulation, the greater the tension produced, which will cause severe pain in the anus. Due to the effect of the inflammatory mediators released by the tissues in the inflamed area, the capillary network in the inflamed area expands extensively and lastingly. Arterial bleeding is the main cause of hemorrhage in anal fissures.
3. Hyperplasia: Inflammatory cell infiltration has a longer course, leading to the proliferation of histiocytes, fibroblasts, vascular endothelial cells, macrophages, and mesenchymal cells in the tissues of the inflammatory focus area. Due to the stimulation of inflammatory mediators, the marginal tissues of the anal fissure are proliferated and thickened, or split hemorrhoids are formed. Fibrinogen in the exudate can form cellulose, which is convenient for tissue repair, resulting in fibrosis and hardening of the base tissue of anal fissure and loss of elasticity, or the formation of a shallow fistula at the base of anal fissure ulcer.
2.4 Clinical manifestations and types of anal fissure
2.4.1 Clinical manifestations of anal fissure: the typical symptoms are pain, constipation, and bleeding. Dry and hard stools directly rub the ulcer surface and prop up the crack during defecation, causing severe pain. After the stool is discharged, the pain is temporarily relieved. After a few minutes, the sphincter reflex spasm causes intense pain for a long time, and some require analgesics. Can be relieved. Therefore, patients with anal fissure fear defecation, which aggravates constipation and forms a vicious circle. There may be a small amount of bleeding when the wound surface is split, and blood on the surface of the stool or dripping after the stool can be seen. Chronic anal fissures are deep and hard, pale in color, and not easy to bleed. Sentinel hemorrhoids, anal papilla hypertrophy, anal sinusitis, and undercover fistula can be seen below the crack.
2.4.2 The clinical classification of Western medicine mainly includes the following
1 Two-stage classification
Acute anal fissure: After anal canal skin injury, there is no induration of fresh wounds, no nipple hypertrophy and skin hemorrhoids.
Chronic anal fissure: repeated infections of the wound, stale granulation, induration on the wound edge, circular internal sphincter fibers on the wound surface, and nipple hypertrophy and skin hemorrhoids, or combined with subcutaneous fistula.
2 Five-type taxonomy
(1) Anal fissure of stenosis: Anal pain, often accompanied by anal sinusitis, and spasmodic contraction of the internal sphincter causes anal stenosis.
(2) Prolapsed anal fissure: due to internal hemorrhoids mixed hemorrhoids, anal papilla hypertrophy, prolapse, inflammation, causing anal fissure, the pain is mild, and there is no obvious anal stenosis.
(3) Mixed anal fissure: It has two characteristics of narrow type and prolapse type at the same time.
(4) Fragile anal fissures: skin diseases around the anus, which cause fragility and stagnation of the anal skin, resulting in multiple shallow anal fissures.
(5) Symptomatic anal fissure: Anal canal ulcers caused by ulcerative colitis, Crohn's disease, anal tuberculosis, etc., or other diseases and delayed wound healing after surgery.
3 five classifications
1) Acute simple anal chapped stage: the initial anal canal tear.
2) Acute anal erosion stage: due to mechanical irritation and repeated infection of the wound, the ulcer surface is sunken, the wound edge is irregular, no induration is formed, and the scar is not obvious.
3) Chronic ulcer stage: There are three typical characteristics of anal fissure.
4) Multiple anal ulcer stage: There are many superficial anal ulcers throughout the anal canal, the flexibility of the anal canal disappears, and it is hypertrophic. This situation is mostly caused by long-term use of laxatives, violent use of anal instruments or examinations and chronic anal skin diseases. The pathological changes are mainly acute simple anal fissure or subacute anal erosion.
5) Prolapsed anal fissure: The anal canal is torn and ulcers are formed due to long-term prolapse of hemorrhoids, nipple hypertrophy and other diseases.
At present, the two-stage classification is common in clinical practice. As a watershed between conservative treatment and surgical treatment, the second-stage classification is simpler and more practical.
2.5 Treatment of anal fissure: The principle of treatment of anal fissure should be for the purpose of relieving pain and promoting ulcer healing, and treat different lesions reasonably. It is generally believed that conservative treatments should be adopted for early fresh anal fissures, local medication, including anal and injections. Surgical methods should be used for old anal fissures, lateral internal sphincterotomy should be the first choice if there are no serious complications, and posterior anal fissure resection or anal fissure resection and skin grafting should be used for subcutaneous fistulas, nipple hypertrophy and sentinel hemorrhoids. .
2.5.1 Conservative therapy
At present, the medical treatment of anal fissure by western medicine mainly includes the following aspects:
1botulinum toxin (BT)
BT used to treat anal fissures started in 1990. It is a neurotoxin released by botulinum to prevent the release of acetylcholine from the presynaptic axon terminal, and the function of the synapse can be restored within 12 weeks. The use of toxins in the treatment of chronic anal fissures was first reported by Jost. Injection of botulinum toxin into the internal and external sphincter can relax the internal sphincter, but after injection into the internal sphincter, the external sphincter has no relaxing effect. It is currently believed that the external sphincter has nothing to do with the cause of anal fissure, but it can actively control defecation, so it should be avoided to paralyze it. Usually at least 15 units of botulinum toxin A need to be injected to make the maximum resting pressure of the anal canal drop significantly"49.
The BT injection method does not require local anesthesia for the treatment of anal fissure, and its injection technique is also simple and easy
Science. Regarding the injection dose is not fixed, to a certain extent, the drug dose is related to the sphincter tension. If the tension of the anal sphincter is high, the dosage should be increased accordingly. During injection, in order to accurately grasp the dose and reduce damage, an insulin syringe should be used and a fine needle should be used. Generally, no special treatment is required after injection, just keep the anus clean and just take a bath after going to the toilet. BT injection usually takes effect within a few days, and pain relief can be seen within 2 days. The most obvious relaxation of the anal sphincter is 4 to 7 days after the injection, generally lasting 4 weeks, after which the effect gradually disappears, and the effect of BT can last for several months.
The main side effect of BT used to treat anal fissures is anal incontinence. The problem of anal incontinence must be explained to the patient before surgery. Patients with low preoperative anal sphincter tension have a higher incidence of postoperative anal incontinence. In addition, women are more likely to have postoperative anal incontinence than men, and the possibility of postoperative anal incontinence in prolific women and the elderly is particularly high. However, anal incontinence caused by BT injection is temporary, and is generally limited to gas and liquid fecal incontinence, and solid fecal incontinence rarely occurs. When the effect of BT gradually disappears, anal function can gradually return to normal.
Regarding the efficacy of BT in the treatment of anal fissure, generally reported results are very good. In a prospective randomized double-blind controlled study, Maria50 et al. found that the healing rate of chronic anal fissures was 73% within two months after injection of BT10 units on both sides of IAS, while the healing rate of the control group injected with saline was only 13 %o Brisinda51 et al. compared the curative effects of BT injection and glyceryl trinitrateointment (GTN) topical in the treatment of chronic anal fissure. 50 patients with chronic anal fissure were randomly divided into BT group and GTN group. Two months later, BT Anal fissures healed in 24 out of 25 cases in the GTN group, and 15 out of 25 cases in the GTN group healed. No anal incontinence was found in either group. One case in the BT group who did not heal was switched to GTN, while 9 cases in the GTN group who did not heal were switched to BT treatment. As a result, all 10 cases were cured. After about 15 months of follow-up, there was no recurrence.
Contraindications of BT in the treatment of anal fissure: Local fistula or perianal abscess of anal fissure is an absolute contraindication of BT therapy. Abnormal blood coagulation function and taking anticoagulants are relative contraindications of this therapy. The main disadvantage of BT treatment is that it is expensive. In addition, some patients have temporary anal incontinence.
2 Nitric oxide donor: Studies have shown that the medium of IAS relaxation caused by NANC pathway stimulation is NO. Studies have found that topical application of nitric oxide donors can reduce the pressure of the anal canal, which makes people think of the application of nitric oxide Body as a form of chemical internal sphincterotomy. Its representative drug is glyceryl trinitrateointment (GTN).
There have been many prospective randomized controlled studies on the treatment of chronic anal fissure with GTN. Lund52 et al. conducted a prospective randomized double-blind controlled study on 80 patients with chronic anal fissure, using 0.2% GTN, twice a day, within 8 weeks. The healing rate of cracks was 68%, while the healing rate of the placebo control group was only 8%. Kennedy reported that with GTN 3 times a day for 4 weeks, the healing rate was higher than that of placebo (46% vs. 16%), but in long-term observation, 35% of patients underwent sphincterotomy. A study by Carapetti and others at St Mark's Hospital in London showed that increasing the dose of GTN did not increase the efficacy, but did not increase the incidence of headaches.
Evans53 et al. compared the effects of GNT and lateral resection, 65 patients were included in the observation, 31 cases in the lateral resection group, and 34 cases in the GTN group. The healing rate of the anal fissure in the GTN group after 8 weeks of medication was 60.% in the surgical group, 97%. In the GTN group, 12 patients underwent surgical treatment, while 9 of the healed patients in the GTN group relapsed.Poor tolerance and poor patient compliance are important factors influencing the efficacy of GTN. Songun54 et al. used isosorbide dinitrate to treat 100 patients with anal fissures between 1997 and 2000. As a result, 93 cases of anal fissure healed within 8 weeks, and 7 cases of ineffectiveness were switched to surgery. Of the 93 patients who healed, 13 patients relapsed within 1 year of follow-up, 7 of which were cured again with ISDN, and the other 6 received surgery. Seven patients experienced transient headaches during treatment. Griffin et al. applied 400 mg of L-arginine locally to the anal margin of volunteers, and performed anal pressure measurement 2 hours later. The results showed that L-arginine can reduce the maximum resting pressure of the anal canal by 46%, which is extremely different from placebo. No side effects were found during the application. Therefore, it is believed that L-arginine significantly reduces the maximum resting pressure of the anus, has a fast onset, and lasts for at least 2 hours. Later, the study by Acheson et al. showed that the effect of L-arginine in reducing sphincter tension has nothing to do with NO, and that osmotic pressure and pH may be the main factors.
3Calcium channel blockers
Calcium channel blockers reduce the contractility of myocardium and smooth muscle by limiting the influx of calcium ions in cells. Commonly used in such drugs are nifedipine and diltiazem hydrochloride (DTZ). It has been reported that after oral administration of calcium channel blockers nifedipine and DTZ in healthy volunteers, the average resting pressure of the anal canal decreased by 21% to 28 0/ Si. 540. In addition, reports have shown that oral nifedipine and DTZ can heal anal fissures. Knight et al. prospectively studied the effect of topical application of 2% DTZ ointment in 71 patients with chronic anal fissure. The medication time was 2-16 weeks, with an average of 9 weeks. Results 51 cases (75%) of the anal fissures healed 2 to 3 months after topical medication, 17 cases of unhealed patients continued medication for 8 weeks, and 8 cases healed. 59 out of 67 follow-ups
Kocher et al. used a prospective randomized double-blind trial to compare DTZ and GTN in the treatment of anal fissures. The results showed that there was no significant difference between the two in the symptom improvement rate and the anal fissure healing rate, but the side effects of GTN such as headache and gastrointestinal reactions (Abdominal pain, nausea, vomiting, diarrhea) more than DTZ
A large multicenter randomized double-blind controlled study compared 2% nifedipine emulsion with 1% lidocaine + 1% hydrocortisone acetate emulsion (both 2 times a day for 3 weeks) for acute anal Treatment effect of fissure. Both groups of patients used anal expanders at the same time. After 4 weeks, 98% of the nifedipine group healed, and 61% of the control group. No systemic side effects were found in the nifedipine group. Topical use of nifedipine can reduce the maximum resting pressure of the anal canal by 300/. Oral nifedipine is also effective for chronic anal fissures. Studies have found that after 8 weeks of oral nifedipine (20 mg, twice a day), 60% of the anal fissures healed completely, and another 20% refused further treatment because of the disappearance of symptoms. Common side effects of nifedipine treatment include mild headache, flushing, and swelling on the foot. Anal incontinence has not been reported. The maximum resting pressure of the anal canal decreased by 36% after taking the first dose of nifedipine
Other drugs: Some people in the early stage of anal fissure have advocated the use of silver nitrate or dry haemorrhoids to treat the fissure, but it is easy to form scars after cauterization, which affects healing. Now they are used sparingly. Some other drugs are used to treat anal fissures. A certain effect has been achieved, but further clinical verification is needed. These drugs such as methyl choline carbamate (bethanechol), which is a cholinergic agonist, a study by Carapeti55 of St. Mark’s Hospital in London found that O. I% bethanechol glue can reduce the maximum resting pressure of the anal canal. The range can reach up to 24, and at the same time it can heal anal fissures. The study did not find obvious side effects. Indole piperamine (indoramin) is an adrenergic receptor antagonist that can reduce the resting pressure of the anal canal. Pitt et al. used a computerized randomization method to divide 23 patients with chronic anal fissure into 14 cases in the indopyramide group, oral indopyramide (20 mg, 6 weeks), and 9 cases in the placebo group. 1 hour after the indole amine group The maximum resting pressure of the anal canal decreased, while the maximum resting pressure of the anal canal in the placebo group did not change significantly. However, there was no significant decrease in anal pain after 6 weeks of medication, and only 1 case of anal fissure healed. In addition, studies such as phosphodiesterase inhibitor and Jones have shown that all phosphodiesterase inhibitors (such as vinpocentine, trequinsin, rolipram, etc.) can cause a decrease in IAS tension, and the extent of the decrease is related to the dose.
In short, in recent years, people have done a lot of work in the drug treatment of anal fissures and made outstanding progress.
2.5.2 Surgical therapy
Surgical treatment of anal fissures has a history of hundreds of years. As early as ancient times, there have been treatments such as cauterization, incision, and thread hanging. In 1818, Boyer proposed the lateral anal sphincter incision method for anal fissure, and Recamier proposed anal dilation in 1838. In 1833, Dupuytren published the posterior median incision of the anal fissure. Mazier counted 32 methods of anal fissure surgery in the literature. Various methods have their advantages and disadvantages. At present, the most commonly used surgical methods at home and abroad are the following
1 Anal dilatation: It is suitable for patients with stage I and II anal fissure, without sentinel hemorrhoids, anal papillary hypertrophy and subcutaneous fistula. Its purpose is to expand the IAS through manipulation, reduce the tension of the IAS, relieve its spasm, and make the anal fissure heal. Generally need to expand the anus to 4 fingers and continue for a period of time. For men, it is easier to expand the sphincter muscles forward and backward due to the narrow pelvic outlet. For women, the sphincter should expand to the left and right. D. Sanam and Singh simply dilated the sphincter under local anesthesia and achieved good results in 97% of patients. Watts et al. performed anal dilatation on 99 patients with anal fissures. All patients were followed up for at least 5 months. Three-quarters of the patients had their symptoms relieved within 48 hours, and 20% of the patients had their symptoms resolved within two weeks. Six patients still had anal dilatation. crack. The curative effect is satisfactory, but its disadvantage is that it often causes the tear of the sphincter muscle and causes the symptoms of anal incontinence. Speakman et al. examined 12 patients with fecal incontinence after dilatation of the anus and found that 11 cases had obvious IAS ruptures, and 3 cases were also accompanied by EAS injuries. Nielsen et al. conducted anal ultrasound and questionnaire follow-up on 32 patients after anal expansion. 4 patients had mild anal incontinence. Of the 20 patients underwent anal ultrasound examination, 13 patients had sphincter defects, and z patients had anal defects. Incontinence, 11 cases had no anal incontinence. Among the sphincter injuries, 9 cases were IAS, 1 case was EAS, and 1 case was both internal and external sphincter injuries. I think that sphincter dilatation is inevitable to the patient’s ability to control defecation and exhaust, but the degree of damage is different. As long as we prevent the support of the anterior sphincter from being damaged, we use it for good recovery. Young people, then this method is still a very effective treatment.
Brodie first performed anal sphincterotomy in 1839. In 1951, Eisenhammer first proposed internal sphincterotomy to treat anal fissures. The internal sphincterotomy is traditionally performed at the posterior midline IAS. However, due to the possibility of keyhole deformity and the difficulty of healing of anal canal skin defects, Park advocated lateral internal sphincterotomy in 1967. Cut off half of the internal sphincter during open surgery. So far, lateral internal sphincterotomy is still the most commonly used surgical treatment for anal fissure. Most of the methods used in China are lateral internal sphincter excision. The method is to make a 1-1.5cm longitudinal incision at the anal margin, use mosquito forceps to pick out the lower edge of the internal sphincter, cut the internal sphincter on the forceps, and then stop the bleeding Suture the incision. Notaras and Goligher modified Park's lateral internal sphincterotomy and suture, and proposed a subcutaneous lateral internal sphincterotomy. The Notaras method is to insert a scalpel into the submucosa and cut the internal sphincter from the inside to the outside. The Goligher method is the opposite. It advocates cutting off hemorrhoids and anal fissures, inserting a scalpel between the internal and external sphincter muscles, and cutting the internal sphincter from the inside to the outside. The surgical treatment of anal fissure has a high healing rate, 95% can heal, and the recurrence rate is low ((1%-3%), however, permanent fecal incontinence may occur after surgery. According to literature reports, the incidence of gas incontinence 3% to 36%, 4.4% to 21% of feces contaminated underwear, and the incidence of fecal incontinence was 0.4% to 4.9%. For the causes of incontinence after internal sphincter incision, people have also conducted some studies. Sultan et al. The scope of the sphincter incision was examined by anal ultrasound. 15 patients were examined by ultrasound before and after surgery, 9 of 10 female patients, and 1 of 5 male patients inadvertently cut the full length of the IAS. Three female patients complained of exhaust incontinence. In female patients, due to their short anal sphincter, the length of the sphincter incision is often longer than expected. In addition, Farouk et al. pointed out that sometimes during sphincterotomy Will damage the external sphincter. In the anal ultrasound examination of the patients who did not heal after the internal sphincterotomy, it was found that some had EAS damage. Excessive enthusiasm for sphincterotomy and inaccurate sphincterotomy can lead to anal incontinence. Female patients have short anal sphincter muscles and can cause potential sphincter damage during delivery. Therefore, female patients are at greater risk of anal incontinence after sphincterotomy.
In order to reduce the risk of postoperative anal incontinence, some scholars have made some improvements in surgical techniques. Escatori et al. used internal sphincterotomy under the guidance of pressure measurement, and decided the operation based on the result of the maximum resting pressure. They randomly divided 40 patients with anal fissure into a standard lateral resection group and a manometric guidance group. As a result, the postoperative stool-contaminated underwear rate and recurrence rate of the manometric guidance group were lower than those in the standard lateral resection group. Littlejohn and Newstead (1997) reported They used tailored lateral sphincterotomy (tailored lateral sphincterotomy) to treat 287 cases of anal fissure patients. Their surgical operation is more conservative than standard internal sphincterotomy, and the scope of IAS incision is only to the anal fissure. Length, rather than reaching the tooth line. Postoperative gas, liquid and solid fecal incontinence rates were 1.4%, 0.4%, and 0.2%. The postoperative recurrence rate was 1.7%. This method is better than the standard lateral incision Law is safer
2.5.3 The latest research progress of anal fissure surgery
With the continuous in-depth study of the local anatomy and physiology and pathology of the anus, there are more and more new treatment methods for anal fissure surgery. Since 1994, Li Jingwen 56 and others have adopted the "vertical cut and half suture method": a vertical incision is made in the anal fissure. . With the incision as the center, the left and right horizontal incisions are about 1. 5--2 cm at the 1/3 of the tooth line. To trim loose skin tissue and inflammatory hyperplasia skin tags. Make the skin smooth after suture. Reduce the occurrence of skin hematoma It also pushes the skin of the anal canal upward. Therefore, the circumference of the anal canal increases. The blood circulation of the anal canal is improved. Therefore, it can heal quickly after suture. And avoid the occurrence of anal canal skin stenosis and postoperative scar pain. The operation was simple without any side effects. 100 cases were followed up for 2 years in 16 cases. 1 year and 6 months were 30 cases. 1 year was 20 cases. There was no recurrence in the follow-up patients. Zhang Zhengrong 57 uses modified expansion and drainage: After local anesthesia, gently expand the anus with his hands. Then centered on the posterior center of the anus, make a radial incision on the left or right obliquely, insert the index finger of the left hand into the anal canal as a guide, hold the 12 cm curved hemostatic forceps in the right hand, and make a blunt separation along the outside of the internal sphincter to above the tooth line. At 0.1cm, penetrate the inner sphincter with the tip of the forceps inward, and hold the tip of the forceps with the index finger of the left hand to support the inner sphincter, and slowly pull outward to the incision. Then separate the clamps, use a scalpel to incise the skin sphincter band and part of the internal sphincter from the outside to the inside, and then remove the ulcer tear and the edge of the gray hard tissue, such as connective external hemorrhoid tissue, hypertrophic nipple, and inflamed anal sinus Both patients with short tract were resected together, and the wound was appropriately lengthened; the incision was made large in the outside and small in the inside, and the drainage flow was smooth. 520 patients with anal fissure were treated with the looseness of the fingers when expanding the anus with the four fingers. All were cured, and no one case occurred. Symptoms and sequelae were followed up for more than half a year without recurrence, and the total effective rate was 100%. Liu Shenghai 58 et al. used thread-hanging therapy to treat 32 cases of anal fissure, 30 cases healed, 2 cases improved, and no unhealed medical history. The treatment method was as follows: The patient took the bladder lithotomy position, disinfected the skin routinely, and spread the disinfection towel. Use 30 mL of 1% lidocaine for local anesthesia, sterilize the anal canal, expand the anus, perform digital anal examination and anoscopy, first ligate one end of the sterilized rubber band with the end of the ball probe with silk thread. Use a scalpel to make a radiation incision of 0.5 cm in the posterior position 1-1.5 cm from the edge of the anus, insert the index finger of the left hand into the anus as a guide, pass the probe through the base of the breach, and pass through the anus at 6 Pull out, tighten both ends of the rubber band, and tie with silk thread. If there is anal papilla hypertrophy, it is removed at the same time, and those with internal hemorrhoids are injected with Xiaozhiling injection, and then 8 mL of 1% lidocaine injection plus 2% methylene blue 2 mL are injected into and around the surgical wound. The dressing is fixed.
3 The treatment of anal fissure with integrated traditional Chinese and western medicine is a major feature of the treatment of anal fissure in China. Western medicine treatment can completely cure the anal fissure by removing the spastic internal sphincter, but it inevitably increases the pain of the patient's operation. Traditional Chinese medicine treatment focuses on moistening the intestines. Laxative, promote blood circulation and remove blood stasis, strengthen local blood circulation, improve lymphatic reflux and nutrition metabolism, relieve internal sphincter spasm, and achieve the purpose of healing. The combination of the two has a promising future for research.
Xiahou Zhijian 59 et al. treated 300 cases of obsolete anal fissures with the combination of traditional Chinese and western medicine, 279 cases were cured once, and 21 cases were cured twice. The method is to insert needles at 3 and 6.9 points 1. Scm away from the anal edge after disinfection of the lithotomy position, and inject 5-6m1 of long hemp solution at each point. Use a thin probe to insert the needle from D. 2-0. Scm outside the anal fissure or sentinel hemorrhoids, pass through the top of the inner mouth of the anal fissure, and heat the needle with an alcohol lamp to about 400℃ to fully expose the lesion (with Sentinel hemorrhoids should be burned first, and the anal fissure ulcer should be burnt away with an iron needle, and the anal canal sphincter and part of the internal sphincter should be burnt and cut. If the anal canal is severely narrowed, it can be cut at 3 or 9 o'clock, and Jingwanhong or Gengxiang hemorrhoid ointment can be applied to the wound.
He Zhimao 60 uses a combination of internal treatment, surgery and external treatment to treat anal fissures. Before surgery, Wuren Decoction, Weizi Jinhua Pills, Neishu Huanglian Decoction, Jichuan Decoction and other treatments are used to treat congestion. Wounds, post-operative sitz bath, fumigation and dressing of Chinese medicine. 194 cases were treated. Except for 13 cases, which underwent two operations, the remaining 81 cases were cured with one operation. Oral Chinese medicine is suitable for fresh anal fissure or old anal fissure to improve symptoms. For those with blood deficiency and dry intestines, use Runchang pills, for those with blood-heat and dry intestines, use Liangxue Dihuang Decoction, and for those with damp-heat accumulation, use Gegen Qinlian Decoction. For anal fissures with external hemorrhoids or anal fissures with deep ulcers, a subtly lateral internal sphincterotomy is used. For those with prolonged anal fissure, external hemorrhoids or nipple hypertrophy, repeated subcutaneous and ineffective after lateral resection, internal sphincterotomy should be performed under direct vision.
Duan Rongqian 61, etc. combined Chinese and Western medicine into an "anal fissure membrane", and 112 cases of anal fissure were treated by sticking. The cure rate was 80.35% and the effective rate was 96.43%. The production method of the anal fissure membrane is: methylene blue 0.05g, pyracillin 1g, borneol 2g, procaine 1g, prednisone acetate 0.1g, keel 2g, vitamin ADIS drops, distilled water 100ml, glue Sodium methylcellulose 4g. Dissolve procaine, prednisone, and glycerin in 100ml of water in turn, then add sodium methyl cellulose and stir to dissolve it to form a mucilage, grind borneol, pyracillin, and keel into fine powder, over 100 Mesh sieve, add it to the glue and mix well, finally add vitamin AD and methylene blue and mix well, make a film for later use. In the early stage of anal fissure, rinse the anus and anal fissure surface with 1:3000PP solution, dry the anal fissure wound with a dry cotton ball, apply anal fissure membrane to the ulcer surface, and apply it after each bowel movement, usually 3-4 It can be cured just one time. Treat the old anal fissure, fully expose the anal fissure under anesthesia, burn the affected area with a 20% silver nitrate cotton swab to destroy the connective tissue, and then use a 3% hydrogen peroxide cotton swab to repeatedly scrub the ulcer surface to make sure that the dirt inside is washed away, and ulcers are seen After bleeding occurs, stop scrubbing vigorously, soak up the wound with a dry cotton ball, and then apply anal fissure membrane.
4 Prevention of anal fissure
1. Eat a reasonable diet, eat more fiber-containing foods, do not add food to spicy foods, and pay attention to more water to keep the stool smooth, do not forcefully send out dry and hard stools after the formation, use warm salt water enema or Kaisai lotion into the anus to lubricate the bowel movement.
2 Daily hygiene, keep the anus clean locally, wash the anus after going to bed and before going to bed to reduce the stimulation to the anus.
3 Treat the inflammation of the anal crypt in time to prevent the formation of ulcers and subcutaneous fistulas after infection.
4 Avoid excessive force during dilation and anoscopy to damage the anal canal.
5 Treat Crohn's disease, ulcerative colitis and other diseases in time to prevent concurrent anal fissure.
6. Strengthen the body, strengthen the abdominal muscles, and perform qigong, anus massage, and levator anus exercises.
Clinical Study on Kangche Ointment in Treating Anal Fissure
1Materials and methods
1.1 Case selection
1. 1. 1 Diagnostic criteria
It is formulated according to the diagnostic criteria for anal fissure in the "Diagnostic and Efficacy Criteria for Anorectal Diseases in Traditional Chinese Medicine" formulated by the State Administration of Traditional Chinese Medicine.
Fresh anal fissure refers to a simple anal fissure in which the skin and subcutaneous tissue of the anal canal split or form ulcers, and the split is fresh, without nipple hypertrophy, split hemorrhoids, or undercover fistula.
Diagnose based on:
(1) Pain is obvious during defecation, and the pain can be aggravated after defecation, often with constipation and a small amount of blood in the stool. It usually occurs in the middle of the anus.
(2) The skin of the anal canal has a superficial longitudinal fissure, with neat wound edges, fresh base, red color, obvious tenderness, and elastic wound surface.
(3) Has a history of recurrent attacks. Irregular wound margins, thickening, poor elasticity, purple-red ulcer base or purulent discharge.
Classification of syndromes: According to the Chinese Journal of Anorectology published by China Science and Technology Press in February 2002, edited by Ren Jianguo, anal fissures are divided into four types:
(1) Blood heat and dry intestines: constipation, severe pain in the anus during defecation, red sweat on the face, dripping blood or stained toilet paper, bright red, sometimes upset and irritable, full abdomen, short red urine, and mouth Dry throat, red tongue, dry yellow fur, pulse number.
(2) Damp-heat accumulation, poor stool, pain in the anus, blood in the stool, swelling of the anus, mucus from time to time, damp perianal, tired body, and bitter mouth. The tongue coating is yellow and greasy, and the pulse is several.
(3) Qi stagnation and blood stasis, fissure hemorrhoids outside the anus, anal tingling or swelling pain, especially after defecation, anus tightening. The tongue is red and slightly purple, and the pulse is stringy or astringent.
(4) Blood deficiency, dry intestines, dry stools, pain and bleeding during stool, dizziness and palpitations, dull complexion, dry skin, pale tongue and little moss, weak pulse.
1. 1.2 Inclusion criteria
(1) Meet the diagnostic criteria for anal fissure.
(2) The course of the disease is more than 2 weeks.
(3) The age is between 12 and 65 years old.
1. 1.3 Criteria for exclusion of cases
1) It is confirmed by inspection that a crack caused by anal chapped, tuberculous ulcer, syphilis, Crohn's disease and ulcerative colitis.
2 Those who are allergic to this medicine.
3 Patients with severe primary diseases such as heart, cerebrovascular, liver, kidney or hematopoietic system, and mental illness.
4 Those who do not meet the inclusion criteria, fail to use the prescribed drugs, cannot judge the efficacy, or have incomplete data that affect the efficacy and safety evaluation. .
5 Combined with subcutaneous fistula, anal papilla hypertrophy and sentinel hemorrhoids.
6 Pregnant women or those preparing to become pregnant.
A total of 60 patients in this group were randomly divided into experimental group and control group according to the order of visiting time. The experimental group was 30 cases, including 17 males and 13 females, the youngest was 15 years old, the oldest was 58 years old, and the average age was 33.58±9 45 years old; 30 cases in the control group, including 14 males and 16 females, the youngest is 21 years old, the oldest is 59 years old, and the average age is 35.84 ± 8.39 years. The gender and age of the two groups were statistically processed, P>0.5, which was comparable.
1.2 Treatment methods
1.2.1 Drug source and composition
1 Test group: Kang crack ointment-composed of 30g Gongying, 25g Diyu charcoal 25g Didin 20g Angelica 20g Lithospermum 15g Yuanhu 15g Panax notoginseng 10g Rhubarb 10g and other medicines. Medical petroleum jelly is prepared into an ointment according to the ratio of traditional Chinese medicine and petroleum jelly at 1:4, bottled and sealed for later use.
2 Control group: Xiongdan Zhiling ointment (manufactured by Sunflower Pharmaceutical, approval number: National Medicine Zhunzi z23021461)
1.2.2 Drug usage and course of treatment
(1) Test group: Apply Kangchao ointment to the anal fissure once a day.
(2) Control group: Xiongdan Zhiling ointment was applied to the anal fissure area once a day.
A course of treatment on the 7th. During the medication, other drugs for anal fissure treatment were discontinued, and more water was used to keep the stool smooth.
2 Observation indicators and evaluation criteria for curative effect:
2.1 Observation indicators
2.1.1 Hematochezia: using scoring method
3 points for dripping blood in stool, 2 points for stool with blood, 1 point for toilet paper stained with blood, and 0 points for no blood in stool.
2.1. .2 The degree of anal pain: Under the guidance of a doctor, the patient is judged according to his own feelings, using the visual analogue scale (VAS) method. Use a 100mm long line segment, with both ends representing "no pain" (0) and "the most severe pain in imagination" (100 ). The patient marks the corresponding part of the line according to the degree of feeling, from the painless end to the mark The distance is the pain score. Less than 10 is slight pain, 10--40 is mild, 40-70 is moderate, 70-100 is severe pain.
2.1.3 Duration of anal pain after defecation: Record the duration of anal pain after defecation to the gradual relief.
2.1.4 Stool frequency: record the number of bowel movements in a week.
2.1.5 Each defecation time: record the time required for each defecation of the patient.
2.1.6 Other conditions: anal itching and other conditions.
2.1.7 Healing of anal fissure: record the changes in the patient’s anal fissure wound during the observation period, if the anal fissure is healed during treatment, record the time it takes from treatment to healing. If not, record the depth and length of the anal fissure Changes.
2.1.8 Adverse reactions: observe the occurrence of various adverse reactions during treatment.
2.2 Efficacy criteria
Refer to the evaluation criteria for the efficacy of anal fissure in the "Diagnosis and Efficacy Criteria for Anorectal Diseases in Traditional Chinese Medicine" formulated by the State Administration of Chinese Medicine.
Healing: The anal fissure is healed, blood in the stool and anal pain disappear.
Effective: Anal fissures are reduced, blood in the stool and anal pain are alleviated.
Ineffective: the anal fissure has not been reduced, and the symptoms have not improved.
2.3 Statistical methods
Using SPSS10.0 statistical software, t test was used for measurement data, and x'test was used for count data.
3.1 Clinical efficacy
In the test group, 18 cases were cured (60%), 12 cases were effective (40%), and the total effective rate was 100%; in the control group, 15 cases were cured (50%), and 10 cases were effective (33.34%), and the total effective rate was 83.34%.
The comparison of clinical efficacy between the two groups is shown in the table
Cured effective ineffective
Treatment group 18 12 0
Control group 15 10 5
The efficacy of the two groups was analyzed by Ridit, P>0.5. There was no significant difference in the overall efficacy of the two groups.
3. 2 Improvement of blood in stool
Blood in the stool before and after treatment
Blood in stool before treatment Blood in stool after treatment
Treatment group 2.1666± 0.5000±
Control group 2.2333± 1.2333±
P value >0.500 <0.001
There was no significant difference in blood in the stool before treatment between the two groups, and the blood in the stool after treatment was significantly improved.