History taking】 1.
1. Pain: Periodic pain caused by defecation is the main symptom of anal fissure. During defecation, the fecal mass stimulates the nerve endings of the ulcerated surface and immediately causes burning pain in the anus, but the pain is relieved a few minutes after defecation. Later, due to the spasm of the internal sphincter, the pain can last from half an hour to several hours until the sphincter is fatigued and the muscle relaxes, and the pain is relieved. The above phenomenon is clinically known as anal fissure pain cycle. Meng Yong, Department of Anorectal Medicine, Jinan Hospital of Traditional Chinese Medicine
2. constipation: reluctance to defecate due to anal pain for a long time causes constipation, which makes the stool more dry and hard, and constipation can aggravate anal fissure, thus forming a vicious circle.
3. Blood in the stool: when defecating, a small amount of fresh blood is often seen on the surface of the stool or on the stool paper or drops of fresh blood after defecation. Hemorrhage is rare.
4. Perianal itching, discharge, diarrhea, etc.
Physical examination
1. general examination.
2. Local examination.
Acute anal fissure has a short period of onset, with red color, light base, fresh and neat fissures, and no scar formation. Chronic anal fissures are longer, recurrent, with deep, uneven bases, often with hypertrophic anal papillae at the upper end and anterior sentinel hemorrhoids at the lower end, generally known as the anal fissure triad.
Auxiliary examination
Routine examination before surgery.
Diagnosis】
Based on the history of painful defecation with typical intermittent pain cycles and pain cycles, it is not difficult to diagnose either. If the local examination reveals the “triad of anal fissure”, the diagnosis is clear. If there is a lateral anal fissure or multiple fissures, it should be considered as an early manifestation of intestinal inflammatory diseases (such as clonorchiasis, tuberculosis and ulcerative colitis), tumor or venereal disease, especially clonorchiasis, and biopsy can be done if necessary.
【Treatment principles】
The principles of treatment are: softening the stool, keeping the stool open, stopping the pain, and relieving the sphincter spasm in order to interrupt the vicious cycle and promote the healing of the wound. Specific measures are as follows.
1. Keep the stool unobstructed: take laxatives or paraffin oil orally to soften and lubricate the stool, increase fibrous food and cultivate good stool habits to gradually correct constipation.
2. Local sitz bath: use potassium permanganate warm water sitz bath before and after defecation to maintain local cleanliness, and at the same time play a role in promoting local blood circulation and relaxation of the internal sphincter.
3. Anal canal dilatation: It is suitable for patients with acute and chronic anal fissures that are not complicated by anal papillary hypertrophy and anterior sentinel hemorrhoids. After anal canal dilation, it can release the spasm of anal sphincter, so it can stop the pain immediately after surgery. After dilation, the anal fissure wound is enlarged and opened, and the superficial wound can be healed quickly. However, this method can be complicated by bleeding, perianal abscess, hemorrhoid prolapse and short-term fecal incontinence.
4. Surgical treatment.
The following surgical treatments can be used for anal fissures that do not heal for a long time and for which non-surgical treatment is ineffective.
(1) Anal fissure excision Removal of anterior hemorrhoids, anal fissures and hypertrophic anal papillae, and vertical severing of part of the internal sphincter to form a fresh wound and heal by itself.
(2) Internal sphincterotomy The spasm and contraction of the internal sphincter is the main cause of anal fissure pain, so it can be treated by internal sphincterotomy. The common method of internal sphincterotomy.
(3) Posterior internal sphincterotomy.
(1) lateral open internal sphincterotomy.
(2) lateral subcutaneous internal sphincterotomy.
The efficacy standard
1) Cure: After treatment, the symptoms disappear and the wound surface heals.
2. improved: after treatment, the symptoms are reduced.
3. Not cured: no treatment, no improvement of symptoms.
Discharge criteria
Those who achieve clinical cure or improvement.