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Anal Fissure

An anal fissure is a tear or open sore (ulcer) that develops in the lining of the large intestine, near the anus. Anal fissures are quite common, with around 1 in every 10 people affected at some point in their life. They affect both sexes equally and people of all ages can get them. But children and young adults between 10 and 30 years of age are more likely to get anal fissures.[5] Anal fissure symptoms The most common symptoms of anal fissures are: • Sharp excruciating burning pain on defecation. • Minute bleeding resulting in bright red spot on feces and toilet paper Most people delay treatment because of embracement resulting in complications but a timely visit to a GP results in early recovery on conservative management. Diagnosing anal fissures Anal fissure are solely diagnose on clinical history and examination. History includes inquiry about sign and symptoms as well as bowl habits and inquiry about general health. Examination is done slightly separating the buttocks and ulcer can be visualized around anal rim under proper illumination. Digital rectal examination procedure in which your doctor will insert a gloved finger in the anus to examine in inside of the anal canal and rectum. However it is avoided because of excruciating pain that patient experience an deserve only of complicated cases and preferably done under local anesthesia to reduce pain during examination What causes anal fissures? Anal fissures are caused by damage to the anal canal lining resulting in tear and painful ulcer development most cases are caused by long standing constipation. As constipated person passes hard compact stool it can damage the anal canal lining. Other possible causes of anal fissures include: • persistent diarrhea • inflammatory bowel disease (IBD), such as Crohn's disease and ulcerative colitis ( long standing inflammatory conditions of the bowel) • pregnancy and childbirth • occasionally, a sexually transmitted infection (STI), such as syphilis or herpes, which can infect and damage the anal canal • having unusually tight anal sphincter muscles, which can increase the tension in your anal canal, making it more susceptible to tearing In many cases, no clear cause can be identified. Treating and preventing anal fissures Most cases heal without taking any medication or surgical procedure within weeks how ever in some cases the symptoms can persists for as far as six weeks in which case the condition is called chronic anal fissures. Such condition requires proper checkup and a professional advice on the treatment options. The treatment options includes Home Remedies: For avoiding constipation include: • plenty of fiber in your diet, such as fruit and vegetables and whole meal bread, pasta and rice – adults should aim to eat at least 30g of fiber a day • staying well hydrated by drinking plenty of fluids • not ignoring the urge to poo – this can cause your poo to dry out and become harder to pass • exercising regularly – you should aim to do at least 150 minutes of physical activity every week Over the counter medication like paracetamole and ibuprofen can be taken to avoid pain. Stiz bath a practice of soaking the affected area especially after bowel movement in warm bath helps sooth pain and promote the healing process. There are a number of different medicines your GP may recommend to help reduce your symptoms and allow your anal fissure to heal. Laxatives These are the medication that helps in smooth passage of feces. Two types of laxatives are used In adults bulk forming laxatives are preferred that increase the bulk of the feces that retain more water and make it smooth and easy to pass. In children preferred laxative is osmotic laxative available in sachets that increase the water content of the feces and helps in easy passage of stool. Painkillers Prolong pain can be relieved by taking medication like paracetamole and ibuprofen as prescribed by the doctor Glyceryl trinitrate Glycerol trinitrate otherwise known as GTN is used in cram formulation and is applied on the affected area 5-6 times a day in minute amount. It works by expanding the vessels increasing blood supply to the fissure increasing healing and also relaxs anal canal mscle to ease passage of feces. A treatment of minimum of 7 weeks is required for proper healing. Most common side effect is headache and light headidness which usulayy leads to non compliacnce therefore applying small quantites of pea size in more divided dose is preffered over large quanties in two divided doses. If the effects become sintolerable reduce the amount until the symptoms settle. Topical anesthetics Topical anesthetics like lidocain are applied on the affected area to reduce pain in severe cases. It has no role in fissure healing however it helps sooth pain. Must be applied for at least 2 weeks by that time most issures begins to heal Calcium channel blockers A medication used mostly to treat high blood pressure can be used topically to treat anal fissures just like GTN they can be applied to the affected area, increasing blood supply and relaxing anal spincter thus helps releing pain and improves healing. Must be used for 6 week as in case of GTN cream. Mostly prescribe in case not responding to other treatment option Botulinum toxin injections Relativel new treatment option invovinfg injesting small quantity iof botlinum toxin at the site fissure that paralyse the anal spincter relaxes smooth muscle that relieve pressure and help in healing of fissureas well as relieve pain.botulinum is apowert fll toxin that can be sued in small amount in case of fiisure under proper setup. It is as effective as GTN cream and effects last for 2-3 months which are enough for fissures to heal Follow-up Few weeks after the use a medication a vist to the doctor is nesscary to acess the condition iof the fissure if they are healing follw up again after few weeks how ever I the medical treatment fails to resolves ulcers in 8 weeks, surgical specialist help is advised i.e a colorectal surgeon Surgery Surgery may be recommended if other treatments haven't worked. It is generally considered to be the most effective treatment for anal fissures, with more than 90% of people experiencing good long-term results. However, it does carry a small risk of complication. Lateral sphincterotomy A lateral sphincterotomy involves making a small cut in the ring of muscle surrounding the anal canal (sphincter) to help reduce the tension in your anal canal. This allows the anal fissure to heal and reduces your chances of developing any more fissures. It is a short and relatively straightforward operation that's usually carried out under a general anaesthetic on a day patient basis. This means you'll be asleep while the procedure is carried out, but you won't usually have to spend the night in hospital. A lateral sphincterotomy is 1 of the most effective treatments for anal fissures, with a good track record of success. Most people will fully heal within 2 to 4 weeks.Less than 1 in 20 people who have this type of surgery will experience some temporary loss of bowel control (bowel incontinence) afterwards as a result of damage to the anal muscles.However, this is usually a mild type of incontinence where the person is unable to prevent passing wind, and usually only lasts a few weeks.[5] Fissurectomy: Fissurectomy Mainly of two type simple and chemical fisurectomy Simple fisssurectomy is a procedure involving removing the scarred superificia;l skin around the anal fissure and excision of any sentinel pile if present … the resulting wound can be left open or closed primarly depending on the overall condtion of the wound . Chemical fissurectomy is process of injecting botulinum toxin as mentioned earlier. Published techniques involve injection dosages that range from 10 to 100 units. Healing rates have varied in the literature, from 67.5% to over 90%, according to a 2012 Cochrane review. [2] Recurrence rates after botulinum toxin treatment are high, and range from 40% to over 50% at 1 year. Incontinence and flatus are common after the procedure; however, they spontaneously resolve in all patients. [3] In comparison with other topical treatments (eg, nitroglycerin), botulinum yields similar results with a lower incidence of adverse events. [4] Advancement anal flaps Advancement anal flaps involve taking healthy tissue from another part of your body and using it to repair the fissure and improving the blood supply to the site of the fissure. This procedure may be recommended to treat long-term (chronic) anal fissures caused by pregnancy or an injury to the anal canal.[5] Complications Complication of fissures surgery depends upon the level of expertise and the type of surgical procedure used as mentioned above includes • Bleeding from the surgical site • Infection preceding the surgical procedure, these requires empirical antibiotic coverage • Fecal in continence • Fissure reoccurrence. • Hemorrhoid tissue prolapsed.

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