Anal fissure K60.20

Author: Prof. Dr. med. Peter Altmeyer

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Last updated on: 29.10.2020

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Synonym(s)

anal fissure; Anal ulcer; Torn Bowel

Definition
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Polyätiological symptom with a longitudinal tear of varying depth in the mucosa of the distal anal canal with pain of varying intensity, especially in defecation (lasting minutes to hours).

Etiopathogenesis
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Chronic constipation (excessive stretching of the anal canal when hard stool masses pass through it), poor blood circulation due to venous congestion in haemorrhoidal diseases, chronic inflammation, chronic viral or bacterial infections, sexual practices.

Manifestation
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Predominantly occurring in middle adulthood.

Localization
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Mostly rear commissure (6 o'clock in lithotomy position).

Clinical features
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Initially superficial defect ( anal rhagade); this merges into the chronic fissure, i.e. linear ulcer reaching down to the fibres of the inner sphincter muscle with inflammatory infiltration of the surrounding tissue. At the distal end of the fissure there are usually mariscs, the so-called pre- or sentinel fold. Symptoms are severe, burning, cramp-like pain during defecation, which can last for hours. Radiation in back, legs, genitals possible. Stool retention and chronic spasm of the inner sphincter muscle with consecutive fibrosis occurs.

Diagnosis
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Examination under local anaesthesia: local anaesthetic injections into the sphincter region, followed by digital examination and proctoscopy.

Differential diagnosis
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Differential diagnosis of anal ulcerations which may occur under the image of an anal fissure.

Complication(s)
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Fistula formation, periproctitic abscess.+

Therapy
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  • Superficial acute fissure: Anal hygiene and warm sitting baths with anti-inflammatory additives (e.g. chamomile extract) or astringents (e.g. Tannosynt, Tannolact) and appropriate ointment therapy. If pain persists, use anaesthetic ointments/supplement/lap inserts (e.g. xylocaine 2% gel), if necessary in combination with anti-inflammatory additives (e.g. Faktu ointment/supplement, haemo-ratiopharm cream/suppository, Posterisan ointment/suppository, DoloPosterine N ointment/supplement). Stool regulation e.g. with wheat bran/ linseed or swelling agents such as agarol, injection of local anaesthetics if necessary. Possibly careful bouginage of the anal canal with sphincter dilators.
  • Chronic fissure:
    • Conservative therapy: Ointments containing glycerol nitrate (e.g. Isoket ointment) or ointments based on calcium antagonists (slackening of the smooth msuculature) such as a 2% diltiazem hydrochloride ointment (Rp.: diltiazem hydrochloride 2.0, base cream DAC ad 100.0; the NRF offers a 2% diltiazem hydrochloride gel - NRF 5.6.)
    • Surgical therapy (various procedures): e.g. lateral sphincterotomy according to Parks with cutting of the inner sphincter muscle, primary wound closure, fissurectomy according to Gabriel with excision of the entire ulcer/fissurectomy, secondary healing.
    • Injection of 20 units of botulinum toxin twice a day for 6 weeks (in clinical trials).

Notice! Glucocorticoids should be used with restraint!

Disclaimer

Please ask your physician for a reliable diagnosis. This website is only meant as a reference.

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Last updated on: 29.10.2020