I. What is an anal fissure?
When your child has painful bowel movements with blood on the surface of the stool; or bleeding from the anus after the stool, consider anal fissure. When your child has painful stools, although there is no blood, also consider anal fissures. 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 anal fissure breaks open again and starts to bleed, and the blood will get on the later discharged stool.
1. anal fissures are tears in the epithelium of the anal canal about 1.5 cm distal to the dentate line, see the rupture site in the figure below.
2, anal fissures are most common in infants and middle-aged adults
3, anal fissures tend to occur in the posterior median line
4, anal fissures are divided into acute and chronic local conservative treatment for 6 weeks can be healed for acute, ineffective for chronic anal fissures.
5, acute anal fissure patients show tearing pain during defecation. Chronic anal fissures are usually less painful.
6. Acute anal fissures may be bright red bleeding, usually just a small amount of blood on the toilet paper or on the surface of the last poop pulled out. Chronic anal fissures may bleed even less or not at all
7. Acute and chronic fissures differ mainly in the performance of the fissure. Acute fissures appear as fresh lacerations, much like paper cuts; chronic fissures have raised edges (have begun to swell) that expose the muscles beneath the fissure, and chronic fissures usually have an external skin tag at the anus, which is also called a sentinel pile, with anal papillae inside the anus The anal papilla is enlarged.
The following is a schematic picture of acute and chronic anal fissures.
The top left picture is an acute anal fissure and the bottom picture is a chronic anal fissure. Here goes the real picture, which is not very disgusting either.
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, and the right picture has 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 sum up, if there is skin flab, it must be chronic anal fissure, and if you can see the swelling of the edge of the fissure, it is also chronic anal fissure, and if the edge is slightly swollen, it may be excessive from acute to chronic.
What is the difference between chronic anal fissure and hemorrhoids?
Chronic anal fissures have skin tags outside the anus (anterior sentinel hemorrhoids). Hemorrhoids, especially external hemorrhoids, also have a mass outside the anus, how to distinguish them?
1. The main way to distinguish between the two is to find out if there is a fissure. Carefully check the front and back median line, if there is a fissure, it is an anal fissure, if not, it is a hemorrhoid.
2. The skin flab of chronic anal fissure is a fibrous hyperplasia caused by repeated stimulation, and the same is true for the connective tissue type of external hemorrhoids, so it cannot be distinguished by the appearance of the flab.
3.But if the external hemorrhoids are of the varicose vein type, i.e., enlarged varicose veins forming round or oval soft masses at the edge of the anus, they can be easily distinguished according to their softness to touch or the color of the vascular mass.
The picture above shows several internal hemorrhoids prolapsing, external hemorrhoids forming a thrombus, and external hemorrhoids respectively.
4. How to treat anal fissure?
What is the purpose of treatment? To remove the cause, to promote the healing of the fissure and to relieve the pain. Anal fissures are firstly recommended to be treated with medication for 8 weeks, and if there is still no effect, surgical treatment can be considered.
1.Remove the cause of the disease
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 in constipation is age + 5-10g per day.
2.Promote fissure healing
① Sitz bath: It can relax the anal sphincter and improve the blood flow of anal mucosa. The method is to immerse the anus in warm water (do not use soapy water), 2-3 times a day for 10-15 minutes each time, dry immediately after the sitz bath or blow dry with a blow splitter, after which one of the following drugs can be applied
② Nifedipine ointment (0.2-0.5%) can increase local blood circulation. Nifedipine ointment needs to be homemade or purchased from the pharmacy of the anorectal hospital. 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 usage is 2-4 times/day for 8 weeks.
③ 2% diltiazem gel, a calcium channel blocker, relieves smooth muscle spasm and increases blood circulation. It is used twice a day for 8 weeks. Homemade method is 300mg in 15ml Vaseline, each tablet is 30mg.
3. Pain relief
2% lidocaine ointment, 2-3/day, or as needed.
After 4 weeks of the above treatment, assess the efficacy and can be used for 8 weeks. If the effect is not good, surgical evaluation can be done to see if the treatment is surgical.