Fissure in Ano & it’s management

Dr. Lakshman SinghB.A.M.S.(Delhi University),M.S.(Ay), BTMAS(SGRH),M.R.A.V (Su.S), Ph.D,

Associate ProfessorFaculty of Ayurveda

Department of Shalya TantraInstitute of Medical Sciences

Banaras Hindu UniversityVaranasi

Introduction

• Anal fissure is the most common cause of severe anal pain. • It is equally one of the most common reasons of bleeding

per anus in infants and young children.• The pain of anal ulcer is intolerable and always

disproportionate to the severity of the physical lesion. • It may be so severe that patients may avoid defecation for

days together until it becomes inevitable.• This leads to hardening of the stools, which further tear

the anoderm during defecation, setting a vicious cycle.

FISSURE IN ANO

• Fissure – This term has been derived from the Latin root “Fissura” that means a cleft, sulks, or groove, normal or otherwise.

• Fissure-in-Ano is a true ulcer in the anoderm. It is longitudinal in shape.Synonyms• Anal ulcer• Anal fissure• Ulcer-in-ano• Chronic ulcer• Faecal ulcer

• Parikartika

FISSURE IN ANO

• An anal fissure is a linear ulcer in the lower half of the anal canal and extends from just below the dentate line to the margin of the anus (anal verge). The ulcer may be acute, recurrent or chronic and may occur alone or with other rectal disease, most commonly haemorrhoids.

EPIDEMIOLOGY

AgeYoung or middle aged adults 30– 50 years

specially; women suffer from fissure the most. Occasionally – infancy or early child hood resulting in acquired mega colon.

Uncommon in aged groups. The cause may be laxity of muscles.

Sex• Fissure is more common in women than men.

Site• Most common site is midline posteriorly. Next

frequent site is midline anterior.• Other sites also are not very uncommon. But

when anal ulcers are more in number, one can suspect associated diseases like tuberculosis, syphilis or colitis.

Gender Ant. Post.

Male 10% 90%

Female 40% 60%

The predominantly posterior midline location of fissures has been explained by

a) Posterior angulation of the anal canal,

b) Relative fixation of the anal canal posteriorly,

c) Divergence of the fibers of the external sphincter muscle posteriorly

d) The elliptical shape of the anal canal

An anterior mid line location of fissure is much more common in women, particularly in those who have borne children.

Etiology

Primary causes

1. Constipation

2. Spasm of internal sphincter

3. When too much skin has been removed during operation for haemorrhoids, anal stenosis may result, in which anal fissure may develop when hard motion passes through such stricture.

Secondary causes

i) Ulcerative colitis

ii) Crohn’s disease,

iii) Syphilis

iv) Tuberculosis

Frontal Section of Anal Canal

The Lining Membrane of Anal Canal

Pathogenesis

In constipation ,during defecation passing of hard faecal mass , mainly on the posterior ano rectal angle in which the overlying epithelium is greatly stretched and torn leading to fissure in ano.

The healing of this fissure is hampered by increased internal sphincter tone.

Faecal matter infection and poor blood supply posteriorly .

If left untreated hypertophied anal papilla above the fissure and skin tag below the fissure are formed.

• At any stage frank suppuration may occur and extend into

the surrounding tissues to from a perianal abscess, which may

discharge through the fissure into the anal canal or may burst

externally to produce low anal fistula.

• Usually the external opening of this fistula lies in or close to

the midline a short distance behind the anus, and an anal

fissure should always be thought of as the commonest cause of

such a median low anal or posterior horse shoe type fistula in

untreated cases.

CLASSIFICATION:

1. Primary or Idiopathic • In this idiopathic type of fissure there is no pre-

existing disease or any other cause except constipation.

2. Secondary or such fissures• anal operation, such as haemorrhoidectomy or laying

open of a low anal fistula, where the resulting wound is situated anteriolry or posteriorly.

• Other condition to which fissures may be secondary are non-specific protocolitis and Crohn’s disease.

Types

Acute fissure- in-ano

Acute fissure in ano is a tear of the skin of the lower half of the anal canal. There is hardly any inflammatory induration or oedema of the edges. Anal sphincter muscle spasm is always present.

Chronic fissure-in-ano • If the acute fissure fails to heal it will gradually develop into a

deep undermined ulcer; termed now as chronic fissure. It is a deep canoe shaped ulcer with thick edematous margins. At the upper end of the ulcer there is hypertrophied papilla. At the lower end of the ulcer there is a skin tag known as “Sentinel pile”.

• Spasm of internal sphincter is always present.

CLINICAL FEATURES• Pain on defecation-sharp,cutting & tearing,

discomfort 2-3 hrs• Bleeding -slight• Swelling –large sentinel tag• Discharge and pruritis-soiling of underclothes• Urinary symptoms -sometimes

COMPLICATIONS

i) Infections: Infection in a fissure may lead to fissure abscess formation. It may also give rise to a fistula-in-ano

ii)Sentinel tag

iii)Enlarged papilla

iv) Anal contracture

DIFFERENTIAL DIAGNOSIS

1) Pruritus ani

2) Ulcerative colitis

3) Crohn’s Disease

4) Squamous cell carcinoma or Adenocarcinoma of rectum

5) Syphilitic fissures-same on opp. wall, discharge-D.G.I. for spirochaetes, wassermann reaction

6) Tubercular ulcer

7) Idiopathic stenosis of internal sphincter- elderly women addict to purgatives

FISSURE IN AYURVEDA

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Etiopathogenesis

Management of Fissure in Ano

I) Conservative treatment

i) Avoidance of constipation

ii) Anesthetic ointment

iii) Anal Dilator

iv) Long acting local Anesthetics

v) Analgesics / Muscle relaxant

vi) Application of glyceryltrinitrate

vii) Botulinum neurotoxin

viii) Hyperbaric oxygen

Sr. No. Condition for conservative

treatment

Condition for surgical

treatment

1. Short and single history of pain Long and continues or

intermittent history of pain.

2. No sentinel tag Sentinel tag.

3. No induration in the edges of fissure Indurations in the edges of

fissure present.

4. Scar is superficial Scar is deep.

5. Fibers of int. sphincter not exposed Fibers of int. sphincter exposed.

6. Mild to moderate pain Severe pain, in acute or chronic

cases of fissure-in-ano.

Criteria for management

Aims and objectives of treatment Complete relaxation of internal sphincter.

Oral pain medication before any anticipated bowel

movement.

Stool softener, weak bulk laxative.

Soothing ointments with anaesthetizing properties may be

applied

Injection of long-acting anesthetic agent.

Application of long Glyceryltrinitrate.

Anal Dilatation

• Intracanal packing is given to avoid soiling during operation.• Digital anal dilatation (stretching of the anal sphincters) - A

procedure similar to that described by Recamier (1829), is done instead of Lord’s procedure.

Technique • With the patient in lithotomy position, the anus is forcibly

stretched by introducing first both index figures and then index and middle fingers of both hands, which maintain a firm distraction for three or four minutes.

• During this manoeuvre the forearms are fully pronated so as to stretch particularly the posterior wall of the anal canal.

Anal dilatation

ANAL SPHINTER STRETCHING

Incision over fissure Revelation of anterior fibres of internal sphincter

Incision of anterior fibres of internal sphincter

dorsal internal sphincterotomy

Lat. sphincterotomy

Excision of Anal Fiss. By Gabriel’s method

Holding of the Sentinel tag

• After stretching the anal sphincters and dorsal internal

sphincterotomy, the sentinel tag is boldly held with the help of Allis

tissue forceps. Thereafter, a semicircular groove is made with blunt

scissor at the base of sentinel tag, to excise the tag.

• excison of sentinel tag is done at the demarcation made by semi circular groove,

• After achieving the secured ligation, the excision of ligated sentinel tag is carried out about 5 mm digtal to ligature to minimise the necrosed tissue and subsequent debris in turn to reduction of post operative infections.

• Gauze soaked with Jatyadi Taila is placed inside the canal One end of the anal packing given initially is withdrawn out for facillating easy removal.

• T-bandage is given to hold the lay on dressing in position.

Insertion of flatus tube

postoperative

• Simple non narcotic analgesics for 24hrs

• Orally allowed after an hour of operation.

• Regular monitoring for haemorrhage is done

without disturbing anal dressing.

Post operative care and prescription • Dressing is removed next morning after that avaghana with is given.

ushnodaka• Frequent ushnodaka avaghana every 12 hourly• Instilation of Ropan sashang / jatayadi taila into the anal canal with the

help of No. 8 rubber catheter attached with a 10ml of syringe.• Triphala gugulu - 2 tablets x BD• Sigru gugulu - 4 gm x BD• Triphala powder - 2 TSF x HS SOS

Samshodhana

Snehan- Narayan Taila, Panchaguna Taila

Swedana-Warm water

Virechana-mridu

Vasti -Samshaman

Langhana

Pachana

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Conclusion• conservative treatments with Ayurvedic method- Samshodhan,

samshaman, are all effective methods that may reduce the need for anesthesia and surgery in many of the patients.

• These could always be offered to the patients who are not willing for operative procedure.

• Surgical manipulation should be sought in case of recurrence or failure of conservative treatment.

• While all the available options are explained to the patient with complete information about the method, cure rates, complications, and reversibility of the disease, the surgeon should analyze the optimum treatment for the particular patient in order to make a good and safe choice and then offer to the patient the result of the best of judgment of his own.

THANK YOU