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Abstract: The patient in this case is Ms. Hu with a first episode of anal fissure. She presented with severe localized anal pain at the time of consultation, and the pain was obvious after defecation. Further medical history revealed a history of constipation in the past, and dry and strained defecation during the onset. In view of Ms. Hu’s first episode, the diagnosis of anal fissure was made through relevant anal visualization and finger diagnosis. After treatment, the mucosal tissue basically healed and the disease was cured.
Basic information】Female, 32 years old
Disease Type】Anal fissure
Hospital】The Affiliated Hospital of Shanxi University of Traditional Chinese Medicine
Date of consultation】January 2022
Treatment plan】Medication (compound cypress liquid application, nitroglycerin ointment, maren soft capsule, rehabilitation new liquid, Puji hemorrhoid suppository, Bifidobacterium tetralactiae tablets, topical recombinant human epidermal growth factor) + life conditioning (bowel habits, dietary habits)
Treatment period】3 weeks of outpatient treatment
Effectiveness】Basic healing of mucosal tissue and healing of disease
I. Initial consultation
Ms. Hu reported that she had severe localized anal pain, especially after defecation, and showed regular pain. Further questioning of her medical history revealed that Ms. Hu had a long history of dry stools and dry and hard stools, and recently there was a small amount of bright red bleeding occasionally after too dry stools or strained defecation. Due to the severe pain in the anus during defecation, Ms. Hu was recently afraid of defecation, which led to her inability to defecate for nearly 3 days, accompanied by a feeling of holding and swelling in the anus. The initial diagnosis of anal fissure was made by finger diagnosis, visual examination and medical history.
(Diagnosis and treatment proposal)
II. Treatment process
Week 1: First of all, it was necessary to relieve Ms. Hu’s pain caused by the acute attack of anal fissure, and it was recommended to use compound cypress liquid application, local hot compress and sitz bath after defecation. In case of severe pain, a small amount of nitroglycerin ointment could also be applied. In addition to the treatment of local fissure cleansing and detoxification, it was also necessary to soften the stool, so regular oral administration of hempren soft capsules was given.
Week 2: Ms. Hu’s pain in the anal canal was clearly reduced and the fissure did not bleed. As the stool enters into good circulation, Ms. Hu can take oral marijuana soft capsule together with oral Bifidobacterium tetrapunctate tablets.
Week 3: The local fissure wound of the anus has basically healed and the stool is significantly more regular than before. Therefore, the dosage and the number of doses of hempren soft capsule can be gradually reduced. Meanwhile, in the later stage, in order to promote the growth of local skin mucosa, topical recombinant human epidermal growth factor can be used to accelerate the growth and healing of wound skin mucosa.
III. Treatment effect
In the second week of treatment, Ms. Hu’s pain in the anus was reduced and the fissure did not bleed, while the stool was regular and smoother than before, and the wetness of the stool increased. In the third week of treatment, the fissure in the anal area had basically healed and the stool was more regular than before. After 4 weeks of outpatient follow-up, the mucosal tissue of Ms. Hu’s anal area had basically healed and the disease was cured. In addition, while treating the fissure pain and promoting the healing of the fissure, establishing good bowel habits also played an irreplaceable role in the treatment of the disease.
IV. Notes
We are glad that Ms. Hu’s fissure was basically healed after treatment, but it should be noted that the basic cause of Ms. Hu’s disease was mainly due to long-term dry stool. Avoid dry stools and prolonged bowel movements, as well as excessive straining during bowel movements. Avoid dry stools, prolonged bowel movements, and excessive straining during bowel movements. If there is local bleeding and pain in the anus, be sure to consult a doctor for review as soon as possible to avoid missing the best time for treatment.
V. Personal insight
Treatment of anal fissures is more common in clinical practice. Since the cause of anal fissures is mostly related to dry stools, as in the case of Ms. Hu in this case, constipation led to anal fissures, patients should be instructed to develop good bowel habits while treating anal fissures, so as to reduce the occurrence of anal diseases by developing good bowel and living habits. Patients with anal fissures are also reminded that if they experience severe localized pain in the anus that worsens during defecation or blood in the stool, there is no need to panic, and they should seek medical attention and treatment as early as possible.