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Emergency And Acute Medicine – Anal Fissure
Basics Description
Hard stool passage causes a linear tear in the anoderm. The fissure typically extends from the dentate line to the anoderm, most commonly in the posterior midline (95%) and less often in the anterior midline (5%). Externally, a skin tag or sentinel pile may form; internally, a hypertrophied anal papilla can be present. Chronic fissures may expose fibers of the internal sphincter with an associated sentinel pile.
Etiology
Increased anal sphincter tone and stress lead to local ischemia of the posterior anoderm. Diarrhea or passage of hard stool can tear the anoderm. Local trauma, including anal intercourse or sexual abuse, may also be causative. Lateral fissures suggest underlying systemic disease such as Crohn disease, anal cancer, leukemia, syphilis, or prior anal surgery.
Diagnosis – Signs And Symptoms
Patients commonly report bright red blood per rectum, usually noted on toilet paper. Pain is sharp, cutting, throbbing, or burning during bowel movements and may persist for hours afterward. Constipation is frequent due to pain-related stool avoidance, often with hard, nondeformable stools.
History
Key historical features include recent constipation or passage of hard stool, episodes of diarrhea, and bright red blood on toilet paper.
Physical Examination
Inspection is performed by gently retracting the buttocks and asking the patient to bear down to visualize the fissure. Severe pain often precludes manual or digital rectal examination; topical anesthetics such as lidocaine jelly or ELA-Max5 may be applied prior to examination. It is important to exclude abscess or tumor.
Pediatric Considerations: A clear test tube may be used as an improvised anoscope to visualize the anal canal and fissure.
Essential Workup
A careful rectal examination is the primary diagnostic step.
Diagnostic Tests And Interpretation
Laboratory testing may include hematocrit if there is a history of severe bleeding. CT pelvis is indicated to exclude anorectal abscess or tumor if a palpable mass is identified.
Differential Diagnosis
Consider Crohn disease, chronic ulcerative colitis, anorectal carcinoma, perirectal abscess, thrombosed hemorrhoid, sexual abuse, tuberculosis, syphilis, lymphoma, leukemia, and prior anal surgery.
Treatment – Prehospital
Establish IV access in patients with significant rectal bleeding.
Initial Stabilization And Therapy
Provide analgesia for patients with significant pain.
Emergency Department Treatment And Procedures
Pain control may include IV, IM, or oral NSAIDs and acetaminophen. Muscle relaxants to relieve sphincter spasm include cyclobenzaprine, diazepam, topical diltiazem 2% ointment, or nifedipine 0.3% ointment. Topical anesthetics such as ELA-Max5 or 2% lidocaine jelly may be used. Sitz baths with warm water help reduce sphincter spasm.
Dietary management includes a high-fiber diet (approximately 20 g/day), psyllium supplementation, and increased oral hydration (10–12 glasses of water daily).
Medications
Common options include cyclobenzaprine, diazepam, diltiazem 2% ointment, docusate sodium, ELA-Max5, ibuprofen, nifedipine 0.3% ointment, and nitroglycerin 0.2% ointment as outlined above.
Follow-Up Disposition
Admission is indicated for severe abdominal pain or distention due to fecal impaction. Most acute fissures are managed conservatively as outpatients; chronic fissures require operative referral.
Follow-Up Recommendations
Colorectal surgery or gastroenterology follow-up is recommended for symptomatic fissures.
Clinical Pearls And Common Pitfalls
A meticulous rectal examination is essential to identify fissures and exclude alternative pathology. Optimal management combines pain control with sphincter relaxation. Discharge instructions should emphasize constipation prevention to reduce recurrence.
Basics Description
Hard stool passage causes a linear tear in the anoderm. The fissure typically extends from the dentate line to the anoderm, most commonly in the posterior midline (95%) and less often in the anterior midline (5%). Externally, a skin tag or sentinel pile may form; internally, a hypertrophied anal papilla can be present. Chronic fissures may expose fibers of the internal sphincter with an associated sentinel pile.
Etiology
Increased anal sphincter tone and stress lead to local ischemia of the posterior anoderm. Diarrhea or passage of hard stool can tear the anoderm. Local trauma, including anal intercourse or sexual abuse, may also be causative. Lateral fissures suggest underlying systemic disease such as Crohn disease, anal cancer, leukemia, syphilis, or prior anal surgery.
Diagnosis – Signs And Symptoms
Patients commonly report bright red blood per rectum, usually noted on toilet paper. Pain is sharp, cutting, throbbing, or burning during bowel movements and may persist for hours afterward. Constipation is frequent due to pain-related stool avoidance, often with hard, nondeformable stools.
History
Key historical features include recent constipation or passage of hard stool, episodes of diarrhea, and bright red blood on toilet paper.
Physical Examination
Inspection is performed by gently retracting the buttocks and asking the patient to bear down to visualize the fissure. Severe pain often precludes manual or digital rectal examination; topical anesthetics such as lidocaine jelly or ELA-Max5 may be applied prior to examination. It is important to exclude abscess or tumor.
Pediatric Considerations: A clear test tube may be used as an improvised anoscope to visualize the anal canal and fissure.
Essential Workup
A careful rectal examination is the primary diagnostic step.
Diagnostic Tests And Interpretation
Laboratory testing may include hematocrit if there is a history of severe bleeding. CT pelvis is indicated to exclude anorectal abscess or tumor if a palpable mass is identified.
Differential Diagnosis
Consider Crohn disease, chronic ulcerative colitis, anorectal carcinoma, perirectal abscess, thrombosed hemorrhoid, sexual abuse, tuberculosis, syphilis, lymphoma, leukemia, and prior anal surgery.
Treatment – Prehospital
Establish IV access in patients with significant rectal bleeding.
Initial Stabilization And Therapy
Provide analgesia for patients with significant pain.
Emergency Department Treatment And Procedures
Pain control may include IV, IM, or oral NSAIDs and acetaminophen. Muscle relaxants to relieve sphincter spasm include cyclobenzaprine, diazepam, topical diltiazem 2% ointment, or nifedipine 0.3% ointment. Topical anesthetics such as ELA-Max5 or 2% lidocaine jelly may be used. Sitz baths with warm water help reduce sphincter spasm.
Dietary management includes a high-fiber diet (approximately 20 g/day), psyllium supplementation, and increased oral hydration (10–12 glasses of water daily).
Medications
Common options include cyclobenzaprine, diazepam, diltiazem 2% ointment, docusate sodium, ELA-Max5, ibuprofen, nifedipine 0.3% ointment, and nitroglycerin 0.2% ointment as outlined above.
Follow-Up Disposition
Admission is indicated for severe abdominal pain or distention due to fecal impaction. Most acute fissures are managed conservatively as outpatients; chronic fissures require operative referral.
Follow-Up Recommendations
Colorectal surgery or gastroenterology follow-up is recommended for symptomatic fissures.
Clinical Pearls And Common Pitfalls
A meticulous rectal examination is essential to identify fissures and exclude alternative pathology. Optimal management combines pain control with sphincter relaxation. Discharge instructions should emphasize constipation prevention to reduce recurrence.
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