Anal fissure?
Consider anal fissures when your child has painful bowel movements with blood on the surface of the stool; or bleeding from the anus after a bowel movement. Consider anal fissures when your child has a painful bowel movement, although there is no blood. Note that when an anal fissure occurs, the stool is not always dry and hard; it may be a thin stool with blood.
Note: Usually, when a bowel movement is first started, the anal fissure does not bleed. When the bowel movement takes a while and the stool stretches the anus, the fissure breaks open again and starts to bleed, and the blood will get on the stool that comes out afterwards.
What is an anal fissure?
An anal fissure is a tear in the epithelium of the anal canal about 1.5 cm distal to the dentate line, see the rupture site below.
Anal fissures are most common in infants and middle-aged adults.
Anal fissures tend to occur in the posterior median line
There are two types of anal fissures: acute and chronic Those that heal after 6 weeks of local conservative treatment are considered acute, while those that do not are considered chronic.
Acute fissures are characterized by tearing pain during defecation. Patients with chronic fissures usually have less severe pain.
Acute fissures may bleed bright red, usually with only a small amount of blood on the toilet paper or on the surface of the last stool. Chronic fissures may bleed even less or not at all.
Acute fissures appear as fresh lacerations, much like a paper cut; chronic fissures have raised edges (which have begun to swell) that expose the muscles beneath the fissure, and chronic fissures usually have an external skin tag at the anus.
External skin tag, also called sentinel pile, and enlarged anal papillae inside the anus.
The following are schematic pictures of acute and chronic anal fissures.
The left picture above is an acute anal fissure and the right picture is a chronic anal fissure. Here goes the real picture, which is also not very disgusting.
Acute anal fissure.
The pictures above are both acute anal fissures, because the fissures are seen when pulling outward on the buttocks, you can see that the fissures are stretched large. The left picture shows white edges and is not swollen yet, while the right picture shows newer fissures and no swollen edges.
Chronic anal fissure.
On the left side of the above picture, the skin is visible and the hypertrophic anal papilla (anal flap) is inside and cannot be seen, as can be seen from the above schematic diagram of acute and chronic anal fissures.
The right side of the picture above shows a chronic anal fissure located in the posterior midline of the anal canal, with the anus inside the circle and the fissure at the arrow, which is visible as a large fissure with raised edges and visible muscles below.
To summarize, if there is a skin flap, it must be a chronic anal fissure, and if you can see the swollen edges of the fissure, it is also a chronic fissure.
What is the difference between chronic fissure and hemorrhoids?
Chronic anal fissures have skin tags outside the anus (anterior hemorrhoids). Hemorrhoids, especially external hemorrhoids, also have a mass outside the anus, so how can you tell the difference?
The main way to distinguish between the two is to look for fissures and check the front and back midline carefully.
In chronic fissures, the fibrous growth is caused by repeated irritation, and in external hemorrhoids, the connective tissue type is also the cause, so there is no way to distinguish them by the appearance of the growth.
However, if the external hemorrhoid is of the varicose vein type, where the enlarged varicose veins form a round or oval-shaped soft mass at the edge of the anus, it can be easily distinguished by its softness to the touch or the color of the vascular mass.
The picture above shows several prolapsed internal hemorrhoids and external hemorrhoids forming blood clots, respectively.
How to treat anal fissure?
What is the purpose of treatment? To remove the cause, promote healing of the fissure and relieve pain. The first recommended treatment for anal fissures is medication for 8 weeks, and if there is still no effect, surgery may be considered.
Removal of the cause.
Treatment of constipation includes a reasonable fiber diet, taking light laxative medication (polyethylene glycol or lactulose) until the stool is regular, etc. When constipation is well, the stool softens and does not continue to hold up the fissured anus. The amount of fiber for constipation is age + 5-10g per day.
To promote fissure healing.
Sitz bath: It relaxes the anal sphincter and improves the blood flow to the anal mucosa. This is done by immersing the anus in warm water (do not use soapy water) for 10-15 minutes 2-3 times a day and drying immediately after the sitz bath or with a blow splitter, after which one of the following medications can be applied
Nifedipine ointment (0.2-0.5%) can increase local blood circulation. Nifedipine ointment needs to be homemade or purchased from the anorectal hospital pharmacy. Nifedipine is 10mg or 20mg per tablet, 0.2% is 20mg in 10ml of Vaseline, 0.5% is 50mg in 10ml of Vaseline. Nifedipine ointment is used 2-4 times/day for 8 weeks.
Diltiazem 2% gel, a calcium channel blocker, relieves smooth muscle spasm and increases blood circulation. It is used twice daily for 8 weeks. Homemade by adding 300mg to 15ml of petroleum jelly, each tablet is 30mg.
Pain relief.
2% lidocaine ointment, 2-3/day, or as needed.
After 4 weeks of the above treatment, assess the efficacy and use for 8 weeks, if not effective, surgical evaluation for surgical treatment.