Anal fissures are ischemic ulcers formed after the general line of the steel tube skin below the dentate line is split in its entirety. The symptoms are predominantly painful. A typical anal fissure is usually associated with periodic pain and bleeding. Patients are mostly young and middle-aged, with a male to female ratio of 1:2.5 and a higher incidence among female young adults. 20-40 years is the high incidence age of the disease, and its onset is in the anterior-middle and posterior-middle position of the anal canal, and less frequently on both sides. The disease is highly prevalent and painful. Old anal fissures can be complicated by pathological changes such as sentinel hemorrhoids, single-port internal fistula, anal papillary hypertrophy, pectineal band formation, and anal sinusitis.
Etiology and pathogenesis
The disease is usually caused by blood-heat and intestinal dryness or yin deficiency and lack of fluid, resulting in constipation and defecation, which causes anal skin fissures, and the evil of dampness and toxicity takes advantage of the deficiency to enter, stagnating the local qi and blood and making it run poorly.
Clinical manifestations
1. Symptoms: Periodic sharp pain in the anus during and after defecation, small amount of blood in the stool, bright red color, 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 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, 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.
Differential diagnosis
1, anal canal tuberculous ulcer: the shape of the ulcer is irregular, the edge is not neat, there is subterranean, the base is dark gray and can be seen cheese like bad since the tissue, there is purulent secretion, pain is not obvious, no fissure hemorrhoid formation, ulcer can occur in any part of the anal canal, most have a history of tuberculosis, secretion culture can find tuberculosis bacilli, or histopathological examination can clearly diagnose.
2.Anal chancre: it can occur in any part of the anal canal, with superficial fissures, no ulcers, fissured hemorrhoids and anal papillomegaly and other complications, mostly caused by perianal skin diseases, such as perianal eczema and dermatitis.
3.Anal canal skin cancer: the ulcer is irregular in shape, with elevated and hard edges, uneven bottom of the ulcer, covered with necrotic tissue on the surface, with special odor, if the cancer tissue invades the sphincter, it can be complicated by anal relaxation or incontinence, the patient has persistent pain, and pathological examination can confirm the diagnosis.
4.Crohn’s disease anal canal ulcer: Crohn’s disease anal canal skin ulcer can occur, the location can be in any position in the anal canal, characterized by irregular shape of ulcer, deep bottom, submerged edge, often co-existing anal fistula. It is also accompanied by features of Crohn’s disease such as anemia, abdominal pain, diarrhea, intermittent low-grade fever and weight loss.
5.Anal canal epithelial defect: history of internal hemorrhoids or other anal surgery, no pain in the anus, or sensory incontinence. There is a full circumferential or partial annular scar around the anal canal, and the rectal mucosa is exposed and often congested and eroded.
6, syphilitic ulcers: common in female patients, the initial itching and stinging of the anus, scratching, decrusting to form ulcers. The ulcers are red, painless, often with a small amount of purulent discharge in the bottom gray, oval or pike shape, often located in the folds on both sides of the anus, with a hard texture and slightly raised edges, and enlarged inguinal lymph nodes bilaterally. The patient has a history of venereal disease, and syphilis spirochetes can be found in the picture of the secretion, and the Wasserman test is positive.
7. Soft chancre: There are multiple round or oval ulcers existing at the same time, soft, with submerged edges and gray necrotic tissue at the bottom, often accompanied by a small amount of purulent discharge, anal pain is obvious, more intense when defecating, the patient has bilateral lymph nodes enlargement, the same ulcers can often be found in penis or labia. The actual fact is that you can find a lot more than just a few of these.
The patient feels itchy in the perineum, and some patients have a burning sensation or anthroposis. The actual fact is that you can find yellowish-brown or reddish papillae or cauliflower-like protrusions, commonly growing in sheets, with uneven surfaces, hard texture, tops, tips, small and fine bases, and foul-smelling secretions.
Treatment
1.Internal treatment
(1) Hot and dry intestine evidence
Symptoms: It is burning pain in the anus, or even red sweating, blood in the stool. Blood is bright red. Blood dripping, or blood on hand paper. The tongue is red, the coating is yellow and dry, and the pulse is solid and slippery.
Treatment: Clearing heat and moistening the bowels
Formula: Xinjia Huanglong Tang with reduction
Raw rhubarb (posteriorly) 9g Mannitol 3g Xuan Shen 15g Radix Rehmanniae 15g Medlar 15g Fried Di Yu 12g Fried Sophora 12g Citrus Aurantium 12g Raw Licorice 6g
Commonly used traditional Chinese medicine: Hemorrhoid Ning Tablets or Sophora Pill
(2) Damp-heat infusion evidence
Symptoms: dry stools, abdominal pain and discomfort, unpleasant defecation, anal swelling, sometimes with mucus and blood, sometimes accompanied by anal eczema, often with a little pus in the anal fissure. The tongue is red, the coating is yellow and greasy, and the pulse is moist.
Treatment: Clearing heat and relieving dampness
Remedy: Si Miao Wan plus or minus
Phellodendron Bark 12g, Atractylodes Macrocephalae 12g, Semen Coix Seed 12g
Commonly used traditional Chinese medicine: Pills for hemorrhoids, Hempren Soft Capsules
(3) Yin (Blood) deficiency and dryness of bowels
Symptoms: 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 not much. Red tongue with little coating, thin pulse.
Treatment: Nourishing Yin, clearing heat and moistening the bowels.
Formula: Zhi Pai Di Huang Wan and Zeng Yi Tang with addition and reduction
Zhi Mu 6g Huang Bai 6g Xuan Shen 6g Mai Dong 6g Huang Lian 3g Bai Shao 6g Ma Ren 6g Mu Xiang 6g Boswellia 6g Myrrh 6g Sheng Gan Cao 6g
Commonly used traditional Chinese medicine: Cistanche Tongxiang Oral Liquid
2.External treatment method
(1) Sitting bath method: Sitting bath before stool can relax the anal sphincter to reduce the stimulation of fissure wound by stool; sitting bath after stool can wash the stool, avoid stimulation of ulcer wound by foreign body, improve local blood circulation, improve the spasm of anal sphincter, relieve pain and promote ulcer healing. It is often used in the form of Wu Bei Zi Tang, Bitter Ginseng Tang and Hemorrhoid Wash.
(2) Dressing method: Apply the medicine to the affected area to relieve swelling and pain, stop bleeding, and remove decay and create muscle. 0.2% nitroglycerin ointment and Ma Yinglong hemorrhoid cream are available.
(3) plugging method: the drug is made into a suppository, plugged into the anus, with swelling, pain, hemostasis and other effects, such as popular hemorrhoid suppository.
3.Surgery
(1) Anal fissure excision: for old anal fissure with sentinel hemorrhoids, subcutaneous fistula, anal papillary hypertrophy and other changes. The advantage of this procedure is that the lesion is completely removed and the recurrence rate is low, but the healing time is relatively long.
(2) Sphincter release surgery: The sphincter bundle is partially removed to eliminate or reduce the spasm of the sphincter, so as to achieve the treatment purpose. The commonly used sphincter release procedures are posterior sphincterotomy, lateral sphincterotomy, lateral subcutaneous sphincterotomy, lateral internal sphincter picking and cutting, etc.
(3) Mobile flap surgery: It is suitable for treating those who have large defect of anal canal skin and anal fissure with obvious narrowing of anal canal and are prone to anal incontinence after internal sphincterotomy, such as elderly people and multiple mothers, etc. It can also be used for those who have low tension of anal canal.
(4) Anal fissure hanging wire surgery: it is suitable for anal fissure with subterranean fistula. To avoid postoperative pain, local injection and incorporation of painkillers are available. Suitable for outpatient treatment.
4.Other therapies
(1) Anal dilation therapy: Hand paper 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. This method should be used with caution in patients with significantly weakened anal sphincter function.
(2) Surface anesthesia method: Applicable to the early stage of anal fissure, for example, 1% dacronin ointment is applied to the affected area in appropriate amount.
(3) Local closure method: Injecting anesthetic drugs and long-acting pain-relieving injections or other compound preparations around the anal fissure to block the vicious cycle of stimulation, i.e. to release the pain and sphincter spasm, so that the fissured wound can be repaired.
(4) Nitroglycerin rubbing method: 0.2% nitroglycerin cream is applied to the affected area to reduce pain, lower the resting pressure of the anal canal and increase the blood supply of the anal canal.
(5) Erosion method: For old anal fissures, use 10% silver nitrate solution or silver nitrate stick, apply to the ulcer, and then rinse with saline until the wound is healed.
(6) cauterization method: that is, the ulcer surface is scorched with high heat, and then the scab falls off to gradually form a fresh wound and achieve the purpose of treatment. There is a soldering iron or metal wire heated and branded, or electric cautery with electric cautery, or cauterization or cutting with carbon dioxide laser, etc.
Referral principles
1.If the diagnosis is unknown and further colonoscopy is needed at a higher level hospital.
2.The conventional treatment is ineffective or the condition is aggravated.
3.Old anal fissures requiring surgical treatment.
Health and rehabilitation
1.To prevent the occurrence of anal fissures, it is crucial to keep the bowels open. Drink more water and exercise to stimulate gastrointestinal motility.
2, pay attention to diet conditioning. More fresh fruits and vegetables and other foods containing more fiber. On the one hand, it can increase the stool volume, on the other hand, stimulate the intestinal wall, promote intestinal peristalsis, conducive to the discharge of feces. These foods are mainly a variety of coarse grains, vegetables, fruits, such as sweet potatoes, wheat, corn, soybeans, bamboo shoots, bok choy, spinach, celery, wild rice, etc.; fat-rich food has a significant laxative effect, mainly walnuts, black sesame, peanuts, sesame oil; honey can lubricate the stomach and intestines, can be used as a remedy for habitual constipation, especially for the elderly and pregnant women constipation.
3.Food therapy
(1) cassia seeds honey drink: fried cassia seeds 10-15g, honey 20-30g. grind cassia seeds, add 400ml of water, decoction for 10 minutes, wash into the honey to mix well to take. It has the effect of laxative and laxative, used for habitual constipation.
(2) 10g of honey, 4-5 walnuts. Pound the walnuts, stir into the honey, and take with warm water before bedtime every day. Suitable for dry bowel constipation.
(3) Fruit yogurt therapy: regular consumption of yogurt can effectively relieve constipation, and the effect is even better when bananas, strawberries and peaches are added to yogurt.
Health education
1, pay attention to local hygiene, warm water sitz bath, keep the perineum clean.
2.Cultivate the good habit of regular bowel movement, do not read books and newspapers when defecating. Don’t be responsible for the toilet, avoid squatting as much as possible, and don’t take more than five minutes to defecate each time.
3.After suffering from anal fissure, early treatment is recommended to prevent the secondary development of other anal diseases.
Commonly used western medicine reference
1.Causalpinia fluviatilis tablets (abortifacient) 1~4 tablets per time, 3 times a day, orally. The dosage can be increased or decreased according to age and symptoms.
2.Mai Zhi Ling 1~2 tablets per time, 1 time each morning and evening, taken orally after meals. For serious illness or early treatment, take 2 tablets each time, twice a day, orally after meals. Suitable for long-term use, or take as prescribed by the doctor.
3.Compound Keratin suppositories (TENA suppositories) 3.4g per capsule, 1~2 capsules per day, administered through the rectum.
4.Mesinazolone suppositories (hemorrhoid suppositories) Each capsule weighs 2g, 1 capsule once a day, and is inserted into the anus before sleep or after stool.
5.Taining cream Each 20g, twice a day, once in the morning and once in the evening, each time with 3~4g of medicine, administered intra-anally.