The Anal fissure – spontaneously occurring linear or elliptical defect mucosa of the anal canal.
The disease occurs quite frequently in the structure of diseases of the colon in the uptake ranked third (11.7 percent) after colitis and hemorrhoids. More than a third of patients are of working age; more likely to affect women in young and middle age.
Fresh (acute) fracture has a slit-like shape with smooth edges, the bottom is the muscle tissue of anal sphincter. Over time, the bottom and edge of the crack is covered with granulation tissue with fibrinous coating. In the long course of the disease (usually more than one month) there is a proliferation of connective tissue at the edges of the cracks, they are sealed, tissues undergo trophic changes. In the area of its inner, and sometimes outer edge of the developing areas of excess tissue anal bumps (“guard bumps”), which further may be formed of a fibrous polyp.
Causes of anal fissures are numerous. The most probable are mechanical and vascular abnormalities, changes perianal epithelium, neuromuscular defects of the anal sphincter. In most cases, anal fissure occurs as a result of injury to the mucosa during the passage of hard faecal masses. Also the occurrence of cracks perhaps due to the trauma contained in the feces or introduced into the anal canal foreign bodies.
Predisposing anal fissure diseases are colitis, proctosigmoiditis, enterocolitis, hemorrhoids, etc. Almost 70% of patients with fracture combined with chronic diseases of the upper digestive tract (gastritis, gastric ulcer and duodenal ulcer, cholecystitis). Have the same percentage of patients have a combination of anal fissure and hemorrhoids.
Symptoms, clinical course
The clinical picture of anal fissure quite characteristic. Irritation of the nerve endings of the mucous membrane with long-term existence of cracks causes a sharp pain and often spasm of the anal sphincter. Tonic spasm of the muscles occurring after a bowel movement, can last for many hours, until the next bowel movement. In these cases creates a vicious circle — anal fissure causes a sharp pain leading to spasm (mainly internal sphincter), which, in turn, prevents the healing of the cracks, causing ischemia of the tissues.
The anal fissure is characterized by a triad of symptoms:
- pain in the anus during or after defecation,
- spasm of the anal sphincter,
- scanty bleeding during defecation.
Pain during bowel movements more characteristic of sharp cracks, followed for chronic. It should be noted that the intense pain forcing patients to seek more rare defecation. This leads to constipation that contributes to the development of constipation. In rare cases when long-existing anal fissure pain may be absent. Pain that increases during a bowel movement, causes spasm of the muscles of the anal sphincter, and he, in turn, only increases the pain. In varying degrees, a marked spasm of the sphincter occurs in approximately 60% of patients.
Allocation of blood from back passage with anal fissure are relatively small, occur during or immediately after defecation and due to trivial trauma to the walls of the cracks. More profuse bleeding usually indicate the presence of other diseases — hemorrhoids, tumors, etc.
Classification and types
When the diagnosis of “anal fissure” a physician usually determines the nature of the disease – “acute anal fissure” or “chronic anal fissure”.
Acute anal fissure – defect mucosa of the anal canal appeared relatively recently and has not yet fallen into the chronic phase.
With acute anal fissure pain, usually strong, constant, but relatively short – only during defecation and for 15-20 minutes afterward. Spasm of the sphincter of acute anal fissure is usually pronounced, and the bleeding usually minimal. Acute fissure usually detected only painful place on the wall of the anal canal.
Over time in the absence of appropriate treatment of acute anal fissure transformirovalsya chronic. In chronic course of the disease the edges of an anal fissure condense, and thicken, they occur in cicatricial changes at the base of the cracks formed polovinnoe, connective tissue thickening – patrol tubercle. In chronic fissure the pain is more prolonged in nature, increases not only when the stool, but in long-term forced position. Patients appear this symptom is the fear of defecation. They’re all more likely to use a variety of laxatives, enemas, become irritable, have insomnia.
At the location of the vast majority of patients with anal fissure is localized at 6 o’clock (posterior anal fissure), 8-9% of the patients, mainly women, on the front wall of the anal canal (anterior anal fissure) and is exceptionally rare (0.5%) was found cracked at its side walls. Sometimes there is a combination of two cracks located on the front and rear walls of the anal canal. The most frequent localization of fractures in the posterior wall of the anus due to the peculiarities of the structure and function of his sphincter. At 6 and 12 hours, especially in the rear, has the worst conditions of blood supply, and there is a high risk of mucosal trauma during defecation.
Complications anal fissures are most often severe pain due to spasm of the anal sphincter, bleeding from the walls of anal fissure and acute abscess that develops as a result of contact infection through a defect of the mucous membrane of the anal canal in adrectal fiber.
Diagnosis of anal fissure starts with careful breeding of the buttocks and inspecting the anus. When breeding the walls of the anal canal the doctor usually detects the crack. In deep “anal funnel” and in obese patients with the developed the layer of fat on the buttocks to detect the crack fails after a long and gradual breeding edges of the anus. In some cases it is necessary to resort to pallavolo study. This study revealed spasm of the sphincter. When treating cracks in an outpatient setting to avoid unnecessary traumatization is better to postpone this procedure until healing of the cracks.
Instrumental methods of diagnostics, such as ANO or rigid sigmoidoscopy, patients with anal fissure with severe pain and spasm of the sphincter without anesthesia are performed. Needed sigmoidoscopy to a height of 20-25 cm can be performed after healing of the fractures, after surgery or before discharge of the patient from the hospital.
Differential diagnosis of anal fissure is relatively simple. It is necessary to differentiate the crack primarily from the incomplete internal fistula of the rectum. By incomplete fistula, as a rule, the spasm of the sphincter is not observed, the pain is significantly less, and the fore purulent discharge from the anus. When digital examination is not painful at the bottom of the ulcer is determined by a clear deepening of the cavity of the fistula. In chronic course of the disease, the fissure is often accompanied by anal itching, proctitis (sphincteric) or proktoshigmoidit.
In the diagnosis of anal fissure you need to be sure that it is ordinary, trivial crack, and not a manifestation of syphilis (Gumma), tuberculosis of the rectum, a rare parasitic (actinomycosis) or other diseases such as anal fissure in Crohn’s disease. In this case it helps a thorough history, as the clinical picture normal anal fissure can occur in different variants and to distinguish it from the specific disease of only using digital to research and anoscopy (rectoscopy) can be very difficult. You must also be aware of possible anal manifestations of acquired immunodeficiency syndrome (AIDS). Still unknown in detail, the picture is clear local changes this terrible disease. Therefore, in patients with a suspicious history (drug addicts, homosexuals) revealed anal fissures and any unusual symptoms should alert the doctor.
Treatment of anal fissures is aimed primarily at the removal of pain and spasm of the sphincter, and further on a normalization of stool and healing of the cracks.
In the “acute anal fissure” about 70% of patients with excellent treatment results can be achieved with the application of different schemes of conservative (drug) therapy combined with strict adherence by the patient to doctor’s recommendations on nutrition, hygiene, exercise and lifestyle.
With “chronic anal fissure” and the futility of purpose of the conservative treatment regimens or the absence of therapeutic effect of conservative therapy within one month, the doctor resorted to a more radical method of treatment – excision of anal fissure. Depending on such factors as the severity of spasm of the sphincter, the location of anal fissures, the presence of the “watch tubercle”, the excision may be carried out as an outpatient procedure under local anesthesia (no hospital admission) and hospital. The main purpose of the excision of the crack is to eliminate scarring it in the edges and bases and establish on its place the “fresh” wounds, which subsequently successfully shivsena medication.
The choice of treatment in each case is carried out by the doctor after examination and depends on patient’s condition and the nature of the disease.
An important factor in treatment is rationally constructed diet, mainly fermented milk – vegetable character, with the exception of sharp, salty, bitter food and of irritating condiments, and alcoholic drinks (including beer). Very good effect in regulating the activity of the intestine, gives a boiled beetroot in the amount of 200— 300 g, passed through a meat grinder or finely chopped and seasoned with vegetable oil or sour cream. In addition, we recommend eating prunes, apricots, dried apricots and figs, which, after washing, pour boiling water and after swelling administered in the diet to 10 PCs 2-3 times a day. Such a diet the majority of patients provides a soft chair. Useful for the same purposes to apply mineral oil 1-2 tablespoons 2-3 times a day. A satisfactory effect can be aimed sunflower oil salad, containing boiled beets (50%), cabbage, carrots. Described diet especially appropriate after-use cleansing enemas and heal the cracks and after surgical treatment, as measures to prevent injury of the mucous membrane in the former site of the earlier cracks.