An anal fissure is a longitudinal fracture of the entire skin of the anal canal or an ulcer. This disease is more common in young adults, more in women than men, and the site of anal fissure is usually in the front and back of the anus in the median position, especially in the later, and fissures located in the anterior median line are more common in women. The main clinical features are periodic anal pain, bleeding and constipation. In Chinese medicine, this disease is called “hooked hemorrhoid” and “fissured hemorrhoid”, etc.
Etiology and pathogenesis
The “Golden Guide to Medicine” says that “the anus is surrounded by folds and ruptures, and those who have knots in the stool are also dry.” Yin deficiency and lack of fluid or heat knots in the intestines to constipation, defecation, can make the anal skin fracture, and then poisoned and gradually formed chronic ulcers.
Western medicine believes that the formation of anal fissure is related to anatomical factors, local injury, chronic infection, and spasm of the internal sphincter.
Diagnosis
1.Clinical manifestations
(1) Pain: Periodic pain is the main symptom of anal fissure, often caused by the expansion of the anal canal during defecation to stimulate the ulcer surface, triggering tearing-like pain, or burning pain, or cutting-like pain, which lasts for several minutes and then reduces or relieves, called the pain interval, usually about 5 minutes; then the sphincter continues to spasm and contract and severe pain, which can last for several hours, making the patient restless and very painful until the sphincter fatigue After relaxation, the pain is gradually relieved, and this process is the anal fissure pain cycle. In severe cases, coughing and sneezing can cause pain, and it radiates to the pelvis and lower limbs.
(2) Bleeding: The amount of bleeding during the stool is small, bright red, sometimes staining the stool paper, or adhering to the surface of the stool, sometimes dripping blood.
(3) Constipation: Most patients have habitual constipation, and because of the fear of pain during defecation, they are reluctant to defecate regularly, so constipation is aggravated, forming a vicious circle.
2.Survey
Longitudinal fissures or longitudinal syringing ulcers of the anal canal can be seen at the time of consultation, mostly located at 6 and 12 o’clock of the truncus position. The spasm of anal sphincter can cause severe pain during finger diagnosis, so finger examination is prohibited. Complications such as superfluous external hemorrhoids and anal papillomegaly can be seen in old anal fissures.
3.Classification
(1) Early anal fissure: the onset is short, only a small ulcer is seen in the skin of the anal canal, the wound is shallow and bright red, the edge is neat and elastic.
(2) Old anal fissure: Early anal fissure is not properly treated and continues to be infected. In the upper part of the fissure near the dentate line, the sinusitis and anal papillitis are complicated, forming a single internal leak and anal papillomegaly. The base of the ulcer is stimulated by inflammation and the connective tissue proliferates, and the pectineal membrane thickens and hardens to form a pectineal band, which hinders the relaxation of the sphincter, resulting in uneven edges of the fissure and lack of elasticity, forming a deeper and larger ulcer that does not heal easily. Pathological changes of fissure, pectineal band, superfluous external hemorrhoid, single internal fistula, anal sinusitis, anal papillitis and anal papillomegaly are the characteristics of old anal fissure.
[Differential diagnosis
1.Tuberculous ulcer The ulcer surface is visible as a cheese-like necrotic material with an uneven bottom, gray color, oval shape, insignificant pain and little bleeding.
2, anal fissures Mostly secondary to anal eczema, anal itching, etc., fissures are more frequent, location is variable, generally more superficial, light pain, little bleeding. It does not cause complications such as superfluous external hemorrhoids and anal papillomegaly.
3, syphilitic ulcers Patients mostly have a history of sexually transmitted diseases, ulcers are not painful, located on the side of the anus and insensitive to palpation. The ulcers are round or shuttle-shaped, slightly raised, hard, and with a small amount of discharge. The inguinal lymph nodes are enlarged bilaterally.
【Treatment】.
Early anal fissures can be treated conservatively, while old anal fissures mostly need to be treated surgically. During the treatment, attention should be paid to prevent constipation and release the spasm of sphincter to interrupt the vicious cycle and promote the healing of anal fissure.
1.Treatment by evidence
(1) Internal treatment
① Blood-heat and intestinal dryness
Symptoms: stool of two or three days, dry and hard, with blood dripping from the stool or blood staining the hand paper, red color of the fissure; abdominal distension and fullness, yellow urine; red tongue, string pulse.
Treatment: Clearing heat and moistening the bowels to improve bowel movement.
Remedy: Cool Blood and Dihuang Tang combined with Spleen and Ma Ren Wan plus or minus.
②Yin deficiency and fluid deficiency
Symptoms: dry stool, one line for several days, pain during stool, blood drops, deep red fissure; dry mouth and throat, irritable heat in the five hearts; red tongue, little or no moss, fine pulse.
Treatment: Nourishing Yin, clearing heat and moistening the intestines.
Direction: Nourishing Yin and clearing heat to moisten the intestines.
③ Qi stagnation and blood stasis evidence
Symptoms: obvious stabbing pain in the anus, especially after defecation, tightness of the anus, purple and dark fissure, stringent or astringent pulse.
Treatment: Regulating Qi and activating Blood, moistening the bowels and clearing the bowels.
Remedy: Liu Mo Tang with safflower, peach kernel, red peony, etc.
(2) External treatment
(1) Early anal fissures: use the raw muscle yuhong ointment dipped in raw muscle powder and apply it to the fissure 1~2 times a day. Take a daily bath with 1:5000 potassium permanganate solution after defecation, or use bitter ginseng soup or pepper salt water to promote blood circulation, maintain local cleanliness and reduce stimulation.
② old anal fissure: available seven three Dan or withered hemorrhoids and other corrosive drugs applied to the fissure, 2 ~ 3 days after decay, change to the use of raw muscle white jade cream, raw muscle San closure. Or use 5% glycerin carbolic acid to rub the affected area, then wipe away with 75% ethanol. In addition, can choose closed therapy, in the long strong point with 0, 5% ~ 1% procaine 5 ~ 10ml for fan injection, every other day, 5 days for a course of treatment; can also be injected in the base of the fissure long-acting pain relief solution (methylene blue 0, 2g, procaine hydrochloride 2g, add water to 100ml, filter sterilization) 3 ~ 5ml, once a week.
2.Other therapies
Old anal fissures and early anal fissures that are not treated by non-surgical therapy can be considered for surgical treatment, and different surgical methods can be selected according to different situations.
(1) Anal dilation method
Indications: Applicable to early anal fissures without comorbidities such as connective tissue external hemorrhoids and anal papillary hypertrophy.
Operation method: In the truncated or lateral position, under lumbar anesthesia, the operator wears rubber gloves and applies lubricant to the index and middle fingers of both hands. The wound of anal fissure is enlarged and opened and drained, and the wound heals quickly. During the operation, care should be taken not to use violence to expand the anal canal quickly to avoid tearing the mucosa and skin. After surgery, use 1:5000 potassium permanganate solution to sit in the bath after the stool every day.
(2) Incisional therapy
Indications: Applicable to old anal fissure with connective tissue external hemorrhoids, papillary hypertrophy, etc.
Operation method: Take a lateral or lithotomy position, local disinfection and anesthesia, make a longitudinal incision in the middle of the anal fissure, up to the tooth line, cut off the pectineal band and part of the circular fibers of the internal sphincter, extend the lower end appropriately, cut off part of the subcutaneous muscle fibers of the external sphincter, so that the drainage can be unobstructed. “The V-shaped open wound is formed with a small top and a large bottom, and the wound is pressed with red ointment gauze and fixed with gauze. After the operation, sit in the bath after the stool every day and change the medicine until it heals.
(3) Lateral incision for anal fissure
Indications: Applicable to old anal fissures without connective tissue hemorrhoids and subcutaneous leakage.
Operation method: in lateral or truncated position, local disinfection and anesthesia, make a longitudinal incision at 37,5px from the anal margin on the anal side, reach the subcutaneous area, expose the internal sphincter and pectineal band with hemostatic forceps, clip the lower edge of the sphincter with two vascular forceps and cut it under direct vision. The incision is usually not sutured, and the drainage is embedded with red ointment gauze.
(4) Longitudinal cut and transverse suture method
Indications: Applicable to old anal fissure with anal canal stenosis
Operation method: Under lumbar anesthesia, take a lateral or lithotomy position, after local disinfection, make a longitudinal incision along the median line of the anal canal, up to 12.5px above the dentate line and down to 12.5px outside the anal verge, cut off the pectineal band and part of the internal sphincter fibers, if there is a subcutaneous fistula, vertebral hemorrhoid, anal papillary hypertrophy, anal sinusitis, trim the wound edge of the fissure, then free the skin at the lower end of the incision to reduce tension Then, use a fine silk thread to enter the needle from the upper end of the incision, slightly with the basal tissue, then penetrate the skin from the lower end of the incision, pull together the silk thread ligature at both ends of the incision, is a longitudinal incision into a transverse suture, generally suture 3~4 stitches, covered with red oil paste gauze, gauze compression, adhesive tape fixation.
(5) Postoperative treatment
Enter liquid diet or soft food for 2 days and control stool for 1~2 days. After the stool, use 1:5000 potassium permanganate solution to sit in the bath, inject Jiuhua cream into the anus to change the medicine, and remove the stitches in 5~7 days.
Prevention and care]
1, develop good bowel habits, timely treatment of constipation.
2, the diet should contain more vegetables and fruits to prevent dry stools and avoid coarse and hard stools to rub the anus.
3. Pay attention to anal cleanliness to avoid infection. After the occurrence of anal fissure, early treatment is advisable to prevent the secondary development of other anal diseases.