1. Overview of anal fissure
Anal fissure is a laceration in the anal area. It is a chronic disease that splits the skin of the anal canal longitudinally and forms infectious ulcers. Among anal diseases, its incidence is second only to hemorrhoids. Both men and women can get the disease. It usually occurs before and after the midline of the anus. It is rare on both sides, and is mostly on the back of the anus. The majority are young female patients between the ages of 20 and 40. Due to anatomical factors, female patients are more common in the anterior midline. It is characterized by periodic pain, bleeding, and constipation in the anus.
2. The etiology and pathogenesis of anal fissure
Traditional Chinese medicine believes that this disease is mostly related to dampness, heat, and blood stasis. A long illness can easily lead to blood deficiency and body fluid deficiency, loss of intestinal tract nourishment and constipation.
Western medicine believes that the occurrence of this disease is related to anatomical factors such as weak anatomical tissue before and after the anus, lack of necessary protection, poor blood supply to local tissues, and insufficient wound healing ability. In addition, it is also related to factors such as mechanical injury, inflammatory factors, sphincter spasm, and congenital anal stenosis.
3. Diagnosis of anal fissure
(1) Clinical manifestations
1. Symptoms Anal fissure usually occurs at 6 o'clock and 12 o'clock in the bladder lithotomy; the symptoms are mainly pain, bleeding, and constipation, and they are mutually cause and effect.
⑴ Pain: It is cyclical, and the pain is aggravated during defecation, showing paroxysmal knife-cutting pain or burning pain. The pain relieves or disappears within a few minutes to more than ten minutes after defecation, which is called the pain intermittent period. Later, the pain was severe due to the persistent spasm of the sphincter, which often lasted for several hours to relieve gradually. In severe cases, coughing and sneezing can cause pain and radiate to the pelvis and lower limbs. The degree and length of pain vary greatly from person to person. Pain is also the main reason for most patients in clinic.
⑵Bleeding: Bleeding can be seen in the stool, usually the toilet paper is stained with blood or dripping blood, the blood is bright red, but the amount is small or only attached to the surface of the stool.
⑶ Constipation: Patients often have habitual constipation. Dry stools often tear the skin of the anal canal and cause anal fissures, and because of fear of pain in the anus during stool, they do not want to defecate regularly, which leads to prolonged retention of stool in the rectum and excessive moisture. Absorption, aggravating constipation, forming a vicious circle.
⑴ Fracture: The wounds of the early patients are fresh, superficial, red in color, soft and without fibrous tissue proliferation. Long-lasting wounds are grayish white, or gray, hard, and can be touched with cord-like induration
⑵ Pathological changes in the anal canal: no pathological changes in the early stage, long-term course of the disease around the wound, anal canal and dental line to form "cylinder mouth"-like thickening, thickening of the comb zone, enlarged connective tissue external hemorrhoids, and anal hypertrophy , Subcutaneous fistula and anal sinusitis, six pathological changes.
(2) Other auxiliary examinations
1. Local inspection The inspection of anal fissure is mainly based on local inspection. The patient generally takes the lateral position, the riding position or the knee-thoracic position. Pay attention to keep warm and light, and ask the patient to cooperate and relax the anus. The examiner uses both hands and index fingers. Gently separate the anus to both sides, from the outside to the inside, check one by one without missing.
2. Others Digital rectal examination, anoscopy and speculum examination, etc., often cause severe pain and aggravate the suffering of patients, and are generally not used as routine examination items.
In short, the main points of the diagnosis of anal fissure are as follows:
(1) Medical history: Most have a history of constipation.
(2) Clinical symptoms: periodic pain in the anus, blood in the stool, constipation, etc.
(3) Anal canal signs: Anal canal skin has longitudinal fissure wounds.
(4) Digital examination or anoscopy: Note that this type of examination is best performed under anesthesia. Common complications of anal fissure can be found, such as sinus or fistula, sentinel hemorrhoids, and anal papilla hypertrophy.
(5) Clinical need to differentiate from anal chapped, anal canal skin abrasion, anal tuberculosis ulcer, Crohn's anal canal ulcer, anal chancre ulcer, early anal canal cancer, anal canal epithelial defect and other diseases.
(3) The stage of disease is generally divided into two stages, namely:
1. Early anal fissure There is a small fusiform ulcer on the skin of the anal canal, the wound is lighter, bright red, the edges are neat and elastic, there is no scar or induration, and the course of the disease is short and easy to cure.
2. Old anal fissures have a history of repeated attacks of anal fissures. Early anal fissures are not treated promptly and properly. The ulcers are pale in color, deep in the bottom, irregular wound edges, thickened like "cylinder mouths", and flat bottoms. The harder, gray tissues (comment band) have poor elasticity and are difficult to heal.
Fourth, the treatment of anal fissure
The principle of treatment of anal fissure is to unblock the stool and eliminate fissures. Soften stools, maintain smooth stools, stop pain, relieve sphincter spasm, interrupt the vicious circle, and promote wound healing.
There are many treatment methods for anal fissure. If it is an early disease, as long as the constipation is actively treated, the stool is kept unobstructed, the ulcer wound is protected, and the infection is prevented, and it can be cured. When early anal fissures are not treated in time and recurrent and form local pathological changes, conservative treatment is often ineffective and surgical treatment is required.
(1) General treatment
1. To adjust the diet should take in foods rich in dietary fiber to increase stool volume, such as crude grain products, beans, potatoes, vegetables, fruits, etc.; try to avoid or reduce spicy foods and condiments, such as peppers and cumin , Curry, pepper, white wine, etc.
2. Appropriate use of laxatives Laxatives can soften stools, such as liquid paraffin, laxatives, maren pills, rhubarb tablets, senna leaves, phenolphthalein, mushroom mixture, etc., pay attention to the dosage when applying, because the amount is small. When it works, large amounts can easily cause diarrhea. The control of the dose varies greatly among individuals, and should be used as appropriate according to the situation of each patient.
3. Develop the habit of defecation regularly. It is generally recommended to defecate before and after breakfast. For patients with long constipation, self-massage can be used. Massage method: starting from the right lower abdomen, and gradually up to the right upper abdomen, upper abdomen, left upper abdomen, left lower abdomen, the technique is first heavy and then light, and when the left lower abdomen is completely relaxed, usually repeat 10-20 times. You can also do some other exercises that help accelerate bowel movements.
4. Relieve mental stress. Most patients with anal fissure are afraid of defecation. When they are not defecate, they will endure the bowel movement first, and they will have to defecate only after having many bowel movements, which will cause dry stool and thick stool diameter. Excretion, anal pain worsens. In fact, in most cases, the stool of anal fissure patients is only dry and hard at the front, and then normal. Therefore, it is very important for the doctor to explain the defecation process clearly to the patient in order to relieve the nervousness of the patient. The author found that many patients after anal fissure surgery still have this kind of psychological barrier to defecation, which makes the patients feel that the operation effect is not ideal.
(2) Internal governance law
1. Blood heat and dry intestine syndrome: constipation, one line for 2 to 3 days, dry and hard, pain in the anus, stained or dripping blood on the toilet paper, red in the mouth; with fullness in the abdomen, yellow; red tongue , Yellow and dry tongue coating, pulse number. Treatment method: clearing heat and cooling blood, moistening the intestines and laxative. Recipe: Zengye Chengqi Decoction. For those with severe bleeding, add Diyu, Sophora japonicus, Puhuang charcoal, etc.; for severe pain, add Yinqiao, Corydalis, Corydalis, constipation, add Maren, whole gualou and so on.
2. Yin deficiency and body fluid deficiency syndrome: dry stools, one line for a few days, periodic anal pain, dripping blood, deep red cracks, irregular wounds; accompanied by dry mouth and throat, five upset heat; red tongue, Little or yellow greasy tongue coating, pulse number. Treatment method: nourishing yin and clearing away heat, moistening the intestines and laxative. Recipe: Yiguanjian or Runchang Decoction. Add Ophiopogon, Polygala, etc. for those who are upset, add hemp, whole Gualou, etc. for those who have difficulty in defecation.
3. Qi stagnation and blood stasis Syndrome: obvious stinging pain in the anus, especially after defecation; anal tightening, dark purple color of the crack; dark purple tongue, yellow tongue coating, stringy or astringent pulse. Treatment method: Regulate qi and activate blood circulation, remove blood stasis and dredge collaterals. Recipe: Modified Liumo Decoction. For severe pain, add dandelion, safflower, peach kernel, red peony, etc.; for constipation, add citrus aurantium, mirabilite, etc.
(3) External governance law
1. Fumigation and washing is suitable for all stages of anal fissure. It has the functions of promoting blood circulation, removing blood stasis, reducing swelling and relieving pain. Commonly used prescriptions include Nepeta,
Sophora flavescens decoction, detoxification decoction, pepper, or 1:5000 potassium permanganate solution, etc., first smoked and then washed, can keep the local clean and hygienic, and can promote blood circulation, reduce irritation, and accelerate healing.
2. The dressing is suitable for all stages of anal fissure. It has the effects of clearing away heat, detoxifying, relieving pain and stopping bleeding. Commonly used are Jiuhua ointment and Shengjiyu
Red ointment, Kangtai ointment, Taining cream (carrageenan), Mayinglong musk hemorrhoid ointment, dragon ball ointment, moist burn ointment, etc., 1-2 times a day.
3. Suppository medicine is suitable for all stages of anal fissure. It has the functions of clearing away heat and toxic substances, reducing swelling, relieving pain and stopping bleeding. Commonly used Indomethacin suppository (indomethacin), Zhichuangning suppository (methazodone), Puji hemorrhoid suppository, Jietai suppository, Taining suppository (carrageenate) and so on.
4. Corrosion Suitable for recurrent old anal fissures. It has the functions of promoting blood circulation, removing blood stasis, decaying and promoting muscle. Commonly used drugs include Baer Dan, Qi San Dan, Hongsheng Dan, and Kuzhi Powder. Or wipe the affected area with 5% carbolic acid glycerin, then wipe off with 75% alcohol. Main usage: Apply a small amount of pill on the old crack, 1 to 2 times a day, after the wound is fresh, use Shengji San to make the wound heal.
(4) Other therapies
1. Anal expansion method is suitable for early anal fissure, no connective tissue external hemorrhoids, nipple hypertrophy and other complications.
2. Sealing therapy is suitable for those with obvious pain in old anal fissure.
(5) Surgical therapy
It is suitable for old anal fissures or early anal fissures that are ineffective in non-surgical treatment.
1. Sphincter lateral incision method is suitable for early anal fissure, without external hemorrhoids, nipple hypertrophy, subcutaneous fistula and other complications.
2. Incision therapy is suitable for old anal fissures, accompanied by connective tissue external hemorrhoids, nipple hypertrophy, etc.
3. Longitudinal section and transverse suture method is suitable for old anal fissures with anal stenosis.
5. Prevention and care of anal fissure
1. Develop good bowel habits, treat constipation in time, eliminate inflammation and avoid mechanical damage.
2. The diet is mainly light vegetarian food, eat more fresh vegetables and fruits, and avoid spicy food.
3. Develop good living habits, pay attention to the combination of work and rest, and actively exercise to enhance physical fitness.
4. Pay attention to keeping the anus clean and hygienic, and clean the anus in time to avoid infection. Once the anal fissure is diagnosed, it should be treated as soon as possible to prevent secondary anal diseases.
5. Local massage and moderate levator anus exercises are effective ways to prevent this disease.