Anal fissures are ischemic ulcers formed after longitudinal full-length fissures of the skin of the anal canal below the dentate line, and they occur in young adults. The pathogenesis is unclear and is mainly associated with internal sphincter spasm and post-injury infection.
[Diagnosis]
I. Clinical manifestations
1. Symptoms: Periodic sharp anal pain during and after defecation, small amount of blood in stool, bright red color, may be accompanied by constipation, anal discharge, itching, etc.
2.Signs: It is usually found in the posterior median or anterior ulcers of the anal canal. Chronic anal fissure may be accompanied by sentinel hemorrhoids, anal papillomegaly, anal sinusitis and submerged fistula.
3.Classification.
(1) Stage I anal fissure: superficial longitudinal fissures of the anal canal skin with neat wound edges, fresh, red base and obvious pain to touch.
(2) Stage II anal fissure: history of recurrent anal fissures. The traumatic margin is irregular, post-increased, poorly elastic, and the base of the ulcer is often gray-white with secretions.
(3) Stage III fissure: the anal canal is tight, the base of the ulcer is fibrotic, there is hypertrophy of the anal papilla, and there are sentinel hemorrhoids near the ulcer, or a subterranean fistula is formed.
Differential diagnosis
It should be differentiated from anal skin fissures, inflammatory bowel disease anal canal ulcers, squamous cell carcinoma of the anal canal, syphilitic ulcers, tuberculous ulcers, etc.
[Identification]
1. Hot and dry bowel syndrome
Burning pain in the anus when passing stool, or even redness and sweating, blood in the stool, bright red blood, dripping out, or blood on hand paper; red tongue, yellow dry coating, and solid and crossed pulse.
2.Damp-heat infusion syndrome
Dry stool not very much, abdominal pain and discomfort during stool, unpleasant defecation, anal swelling, sometimes with mucus and fresh blood, sometimes accompanied by eczema in the anal area, often with a little pus in the anal fissure, red tongue, yellow greasy coating, moist pulse.
3.Yin (blood) deficiency intestinal dryness
Dry stool, difficult to go down, pain in the anus when defecating, pain like pins and needles, bleeding, dry mouth and irritation, not much desire to drink, red tongue with little coating, thin pulse.
[Treatment]
I. Treatment principles
Relieve the spasm of sphincter, relieve pain, soften stool, terminate the vicious cycle, and promote the healing of trauma; simultaneously relieve the accompanying complications; surgical treatment can be used for anal fissure that does not heal for a long time and non-surgical treatment is ineffective.
II. Non-surgical treatment
(I) Chinese medicine treatment
1.Typing and treatment
(1) Heat and intestinal dryness
Treatment: clear heat and moisten the intestines
Example formula: Xinjia Huanglong Tang with reduction
Commonly used drugs: raw rhubarb 9g (later down), mannitol 3g, xuan shen 15g, raw earth 15g, maitong 15g, fried diyu 12g, fried acacia 12g, heliotrope 12g, raw licorice 8g.
2. Damp-heat infusion evidence
Treatment: Clearing heat and relieving dampness
Example formula: Si Miao Wan with reduction
Commonly used herbs: Phellodendron Bark (12g), Atractylodes Macrocephala (12g), Radix Aconiti (12g), Semen Coix (12g).
3. Evidence of Yin (Blood) deficiency and intestinal dryness
Treatment: Nourishing Yin, clearing heat and moistening the intestines.
Example formula: Zhi Cai Di Huang Wan combined with Zeng Yi Tang
Commonly used herbs: Zhi Mu 6g, Huang Bai 6g, Xuan Shen 6g, Mai Dong 6g, Huang Lian 3g, Bai Shao 6g, Ma Ren 6g, Mu Xiang 6g, Cure Lactation 6g, Sheng Gan Cao 6g.
(II) External treatment method
1.Chinese medicine sitting bath
Available to relieve pain like Shen Tang, clear heat and dry dampness, activate blood circulation and relieve pain. Radix Angelicae Sinensis 10g, Cortex Phellodendron 10g, Peach kernel 10g, Betel nut 10g, Saponariae 10g, Atractylodes Macrocephalae 10g, Fructus Bupleurum 10g, Zedoary 10g, Qin Dao 6g, Raw Rhubarb 6g (later down).
2.Topical drugs
Such as 0.2% nitroglycerin cream, Ma Yinglong hemorrhoid cream, etc. A few patients can have headache after using nitroglycerin cream, which disappears after stopping the drug.
3.Anal dilation method
The anal canal can be dilated with handkerchiefs or instruments, to the extent of 3 fingers in one hand. Some patients may have skin lacerations, local hematoma and mild anal incontinence. This method should be used with caution in patients with significantly weakened anal sphincter function.
4.Other
Botulinum toxin A injection is currently used abroad, but it is not yet popular in China.
Surgical treatment
(A) Surgical methods
1.Partial severance of the internal sphincter
It is mainly applied to the stage of anal fissure. It includes
(1) Lateral internal sphincterotomy
It can effectively reduce the complications and recurrence rate of surgery, but complications such as bleeding, pain, infection, anal stenosis, fistula formation and anal incontinence can still occur. It includes both open and closed types.
(2) Partial posterior internal sphincterotomy
The lower edge of the internal sphincter is cut directly through the anal fissure, and sometimes the lower part of the internal sphincter is also cut. The incision is open, healing is slow, and occasionally there is a “locked hole” deformity.
2.Mobile flap surgery
It is suitable for treating patients with large defect of anal canal skin and anal fissure with obvious narrowing of anal canal and prone to anal incontinence after internal sphincterotomy, such as elderly people and multiple mothers, etc. It can also be used for patients with low anal canal pressure.
3.Anal fissure hanging wire surgery
It is suitable for anal fissure with submerged fistula. To avoid postoperative pain, local injection and incorporation of painkillers are available. Suitable for outpatient treatment.
(II) Postoperative complications
1.Anal incontinence
Caution is needed in the surgical treatment of patients with a history of obstetric injury. Anal incontinence due to postoperative “iron hole” deformity requires anthoplasty.
2. Delayed healing or recurrence of trauma
If conservative treatment such as sitz bath and stool softening still cannot heal, partial lateral internal sphincterotomy can be performed again.