The Anal and Intestinal Branch of the Chinese Society of Traditional Chinese Medicine, the Colorectal and Anal Surgery Group of the Chinese Society of Surgery, and the Committee of Colorectal and Anal Diseases of the Chinese Society of Integrative Medicine, based on reference to the Diagnostic Criteria for Anal Fissures (2002, trial draft) and other criteria, combined with the results of evidence-based medical research and expert opinions, formulated the Guidelines for Clinical Diagnosis and Treatment of Anal Fissures for reference by Chinese clinicians.
Anal fissures are ischemic ulcers formed after longitudinal full-length fissures of the skin of the anal canal below the dentate line, and are most common in young adults. The pathogenesis is unclear, but it is mainly related to internal sphincter spasm and post-injury infection.
Diagnosis
I. Clinical manifestations
1. Symptoms: Periodic sharp anal pain during and after defecation, small amount of bright red blood in the stool, may be accompanied by constipation, anal discharge, itching, etc.
2.Signs: Preferably posterior median or anterior ulcers in the anal canal, chronic anal fissure may be accompanied by sentinel hemorrhoids, anal papillomegaly, anal sinusitis, and subterranean sinus.
3.Classification.
(1) Stage I anal fissure: superficial longitudinal fissured ulcers of the anal canal skin with neat wound edges, fresh, red base, and obvious tenderness.
(2) Stage II anal fissure: history of recurrent anal fissures. The traumatic margin is irregular, thickened, poorly elastic, and the base of the ulcer is often grayish white with discharge.
(3) Stage III fissure: the anal canal is constricted, 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 intestine evidence
Burning pain in the anus when passing stool, or even red sweating, blood in the stool, bright red blood, dripping out, or blood on hand paper; red tongue, yellow dry coating, solid and slippery pulse.
2.Damp-heat infusion evidence
Dry stool is 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 relieve, pain in the anus when defecating, pain like pins and needles, bleeding, dry mouth and irritable heart, desire to drink, red tongue with little coating, thin pulse.
Treatment
I. Treatment principles
Relieve sphincter spasm, relieve pain, soften stool, terminate the vicious cycle, and promote wound healing; simultaneously relieve the accompanying symptoms; surgical treatment can be used for anal fissures that do not heal for a long time and for which non-surgical treatment is ineffective.
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 Bai Di Huang Wan combined with Zeng Shui 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, Lactobacillus 6g, Sheng Gan Cao 6g.
(II) External treatment method
1.Sitting bath with Chinese medicine
Pain relief like Shen Tang can be used to clear heat and dry dampness, activate blood circulation and relieve pain. Radix Angelicae Sinensis 10g, Phellodendron Bark 10g, Peach kernel 10g, Betel nut 10g, Soapberry 10g, Atractylodes Macrocephalae 10g, Fructus Bupleurum 10g, Zedoary 10g, Radix Gentianae Macrophylla 6g, Raw Rhubarb 6g (later down).
2.Topical medication
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 medicine.
3.Anal dilation method
Fingers or instruments can be used to dilate the anal canal, to the extent of 3 fingers in one hand. Some patients may have skin lacerations, local hematoma and mild anal incontinence. The 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 stage III 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 can also be cut. If there is inflammatory anal fistula, hypertrophic anal papilla or external hemorrhoid can be removed at the same time. 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 the anal canal and prone to anal incontinence after internal sphincterotomy, such as elderly people, 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 “locked hole” deformity requires anoplasty.
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.