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Anal fissure.pptx

This document provides tips for using a PowerPoint presentation on anal fissures. It recommends: 1. Freely editing, modifying, and adding your name to the slides. 2. Not worrying about the number of slides, as half are blank except for the title to facilitate discussion. 3. Showing blank slides, asking students what they know, and then showing the content slide, in an active learning approach repeated three times. 4. This approach is good for self-study as well. 5. Notes provide the bibliography.

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Tips on using my ppt. 1. You can freely download, edit, modify and put your name etc. 2. Don’t be concerned about number of slides. Half the slides are blanks except for the title. 3. First show the blank slides (eg. Aetiology ) > Ask students what they already know about ethology of today's topic. > Then show next slide which enumerates aetiologies. 4. At the end rerun the show – show blank> ask questions > show next slide. 5. This will be an ACTIVE LEARNING SESSION x three revisions. 6. Good for self study also. 7. See notes for bibliography.
Introduction
Introduction • Anal fissure is a linear or oval shaped ulcer in the squamous epithelium of the anal canal distal to the dentate line. • Occurs equally in both sexes • Tend to occur in younger age groups .
Aetioloty
Aetioloty • Multifactorial • Initiating factors – Posterior perineal descent coupled with excessive stretching of the anoderm: velnerable to tearing – Relatively fixed anococcygeal ligament posteriorly. – Extreme bowel pattern: Hard stool/explosive diarrhoea. – Excessive straining at defication. • Perpetuating factors
Aetioloty (Perpetuating factors) • Intrinsic anal sphincter hypertonia – Reduced production of NO • Relative tissue ischaemia – Paucity of branches of inferior rectal artery – Less dense capillaries in both subanodermal space and within the IAS in the posterior midline • Posterior perineal descent
Classification
Classification • Historically according to duration of symptoms – Acute: symptoms < 6 weeks – Chronic: ≥ 6 weeks – < 6 weeks but examination shows features of chronicity
Classification • Based on morphology of the fissure – Superficial fissure: • severe pain ± bleeding • superficial separation of the anoderm with sharp edges • base of the fissure does not reach the internal anal sphincter • vast majority heal spontaneously within days or within weeks of appropriate conservative treatment. – Deep fissure
Classification • Deep fissure – Deep, often with visible fibres of the internal anal sphincter – Minimal granulation tissue at the base – Wide pear shaped ulcer – Triad of indurated ulcer edges, a distal skin tag (sentinel pile) and a proximal hypertrophic anal papilla. Later is not universal. – Often persist and either tend not to heal without intervention or recur regularly. – May result chronically from prolongation or repetition of the causes of superficial anal fissures or they may arise de novo as a result of a deep tearing right from the start.
Location
Location • Posterior midline: 75% • Anterior midline: 25% • Both anterior and posterior: 3% • Atypical locations or multiple – Crohn’s disease – Trauma – Tuberculosis – Syphilis – AIDS – Anal carcinoma
Symptoms
Symptoms • Anal pain – Predominant symptom – During defecation, may last for several minutes to hours or the entire day. – Like knife cutting • Rectal bleeding – Minimal, bright red • Pruritus ani
Physical examination
Physical examination • Visualised by gentle parting of the buttocks with eversion of anal verge. • Position of fissure • Features of acute/ chronic fissure • DRE, proctoscopy and sigmoidoscopy is of little value. • In acute setting when there is a strong suspicion of secondary pathology these procedures can be done under anaesthesia or when surgery is being undertaken.
Physical examination •
Diagnosis
Diagnosis • Characteristic description of symptoms • Generally easily confirmed by physical examination (inspection only).
Diagnosis • Characteristic description of symptoms • Generally easily confirmed by physical examination (inspection only).
Concomitant presence
Concomitant presence • When the patient complains of anal pain – Perianal abscess – Anal fistula – Inflammatory bowel disease – Sexually transmitted disease – Anal carcinoma • In older, particularly female – Obstructed defecation
• Atypical fissures, painless, nonhealing: – further evaluation via examination – Possible biopsy and cultures.
Treatment
Treatment • Nonoperative: – First line management both in acute and chronic anal fissure. Half of all patients of acute and chronic anal fissure will heal with nonoperative measures. – Not as effective as surgery. Late recurrence is higher (about 50%) with nonoperative Rx. – Associated pain and bleeding from trauma to sentinel piles – Persistent tenesmus or soilage due to the presence of fibrous polyp. – Side effects and non compliance.
Treatment • Operative – For treatment failure – Sentinel piles – Surgical excision of SP and fibrous polyp relieves symptoms and offers good healing for fissure – Has been described as initial modes of treatment. Causes lack of behavioral changes.
Nonoperative management
Nonoperative management • Treat both initiating and perpetuating factors concurrently – Dietary advice, medication, biofeedback – Perineal support • Manual • Modified toilet seat • Sitz baths • Topical preparations
Topical preparation
Topical preparation • Combination of – Anaesthetics – Antiinflammatory – Antibiotic • Erian: – Cinchocaine HCI (local anaesthetics) – Hydrocortisone – Framycetin Sulphate (aminoglycoside antibiotic) – Esculin (coumarin glucoside)
Sphincter relaxants
Sphincter relaxants • 0.2% GTN ointment: two to three times daily for 4-8 weeks. – 77% headache, 6% orthostatic hypotension, anal irritation 67% lack of compliance. – 6 weeks:90% healing rate Vs 85% in LIS – 8 weeks:67% healing rate Vs 92% in LIS – 2 years : 46% ,, ,, Vs 91% in LIS
Sphincter relaxants • 2% diltiazem. – Equally effective in chronic anal fissure. Less side effects. • These are first line treatment in chronic anal fissures. • Who are already on these drugs for HTN and ISD may be unsuitable for these treatment
Sphincter relaxants • Parasympathomimatic: 0.1% bethanechol gel tds • Adrenergoc antagonists: lack of efficacy. • Phosphodiesterase inhibitors (sildenafil): significantly reduces anal sphincter tone
Sphincter relaxants • Botulinum A toxin: exotoxin – Binds with presynaptic nerve terminal at the neuromuscular junction. Prevent release of acetylcholine. Temporary muscle paralysis – Injection of 20 U on each side of anterior midline in the intersphincteric groove. Repeat for persistence – Over all healing rate significantly lower than LIS
Botox (contd…) • Second line agent in the treatment of CAF. • Side effects: • Mild incontinence to flatus (or stool) that is short lived and resolve spontaneously • Perianal haematoma • Pain • Sepsis
Surgical treatment • LIS with excision of SP and fibrous anal polyp. – LIS: open/ closed method – Tailored – ASCRS recommends LIS as the surgical treatment of choice for refractory anal fissure. – External anal sphincter deficits are recognized preoperatively. – Healing rate >90%. Incontinence to flatus in about 15% of patients. – Recurrence : in 70% of patient lack of adequate IAS division founds. LIS on the opposite side is the option.
Surgical treatment • Controlled anal dilatation – Parks retractor opened to 4.8 cm – Pneumatic balloon inflated to 40 mm – Healing upto 94%. Healing rate and incontinence is similar to LIS. – Symptomatic improvement 93% after dilatation Vs 72% after LIS at 4 months in one study. – Still practiced in some centres. Not in North America.
Flap • Indicated in absence of sphincter hypertonia. • Anal cutaneous advancement flap along with fissurectomy • Island/sliding advancement flap .
Recurrence after LIS • Anal manometry and endoanal ultrasound are essential. • Separate patients with low and high resting anal pressure • High pressure: repeat LIS on opposite side.
Atypical anal fissure
Atypical anal fissure • Address the primary disease • Otherwise the management is same. • Among crohn’s patients, anal pathology leading to symptoms identified in 42% of patients. Commonest is the perianal abscess (29.5%), anal fissure (27.6%), anal fistula (26.7%) • AIDS: atypical, deep, broad base fissure.
Get this ppt in mobile 1. Download Microsoft PowerPoint from play store. 2. Open Google assistant 3. Open Google lens. 4. Scan qr code from next slide.
Get my ppt collection • https://www.slideshare.net/drpradeeppande/ edit_my_uploads • https://www.dropbox.com/sh/x600md3cvj8 5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl =0 • https://www.facebook.com/doctorpradeeppa nde/?ref=pages_you_manage