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| {{Infobox_Disease |
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| Name = {{PAGENAME}} |
| | {{Anal fissure}} |
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| Caption = |
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| DiseasesDB = 673 |
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| ICD10 = {{ICD10|K|60|0|k|55}}-{{ICD10|K|60|2|k|55}} |
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| ICD9 = {{ICD9|565.0}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = 001130 |
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| eMedicineSubj = med |
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| eMedicineTopic = 3532 |
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| eMedicine_mult = {{eMedicine2|ped|2938}} {{eMedicine2|emerg|495}} |
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| }}
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| {{SI}} | |
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' | | '''For patient information click [[{{PAGENAME}} (patient information)|here]]''' |
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| {{CMG}} | | {{CMG}}; {{AE}} {{ADS}} |
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| | {{SK}} Fissure in ano |
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| | == [[Anal fissure overview|Overview]] == |
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| ==Overview== | | == [[Anal fissure historical perspective|Historical Perspective]] == |
| An '''anal fissure''' is an unnatural crack or tear in the [[anus]] skin. As a fissure, these tiny tears may show as bright red rectal bleeding and cause severe periodic pain after defecation.<ref name="new">Gott M.D., Peter H. (March 5, 1998) [[The Fresno Bee]] ''New thearpy coming for anal fissures.'' Section:Life; Page E2</ref> The tear usually extends from the anal opening and located posteriorly in the midline. This location is probably because of the relatively unsupported nature of the anal wall in that location.
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| ==Causes== | | == [[Anal fissure classification|Classification]] == |
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| Most anal fissures are caused by stretching of the anal [[mucosa]] beyond its capability. Various causes of this fissure include:
| | == [[Anal fissure pathophysiology|Pathophysiology]] == |
| *Straining to defecate, especially if the [[feces|stool]] is hard and dry
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| *Severe and chronic [[constipation]]
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| *Severe and chronic [[diarrhea]]
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| *[[Crohn's disease]] and [[Ulcerative colitis]]
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| *Tight [[sphincter]] muscles
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| *[[Anal sex|Anal intercourse]]
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| Many acute anal fissures will heal spontaneously. Some fissures become chronic and will not heal. The most common cause for this is spasm of the internal anal sphincter muscle. This spasm causes poor blood flow to the anal mucosa, hence producing an ulcer which does not heal since it is deprived of normal blood supply.
| | == [[Anal fissure causes|Causes]] == |
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| Anal fissures are common in women after [[childbirth]],<!--
| | == [[Anal fissure differential diagnosis|Differentiating Anal Fissure from other Diseases]] == |
| --><ref>{{cite journal |author=Abramowitz L, Sobhani I, Benifla JL, ''et al'' |title=Anal fissure and thrombosed external hemorrhoids before and after delivery |journal=Dis. Colon Rectum |volume=45 |issue=5 |pages=650-5 |year=2002 |pmid=12004215 |doi=}}</ref>
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| and following constipation in infants.<!--
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| --><ref>
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| {{cite journal |author=Martínez-Costa C, Palao Ortuño MJ, Alfaro Ponce B, ''et al'' |title=[Functional constipation: prospective study and treatment response] |language=Spanish; Castilian |journal=Anales de pediatría (Barcelona, Spain) |volume=63 |issue=5 |pages=418-25 |year=2005 |pmid=16266617 |doi=}}</ref>
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| ==Prevention== | | == [[Anal fissure epidemiology and demographics|Epidemiology and Demographics]] == |
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| In infants under one year old, frequent diaper change can prevent anal fissure. For adults, the following can help prevent fissure:
| | == [[Anal fissure risk factors|Risk Factors]] == |
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| *Treating constipation by eating food rich in [[fiber|dietary fiber]], avoiding [[caffeine]] (which can increase constipation),<ref> Basson, Marc D. , "Constipation" emedicine [http://www.emedicine.com/med/topic2833.htm] </ref> drinking a lot of water and taking stool softener.
| | == [[Anal fissure screening|Screening]] == |
| *Treating [[diarrhea]] promptly.
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| *Lubricating the anal canal with KY Jelly or other water-based lubrication before inserting anything (ex: vibrator, penis) into your anal canal.(petroleum jelly is not recommended because it can harbor harmful bacteria).
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| *Avoiding straining or prolonged sitting on the toilet.
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| *Using a moist wipe instead of perfumed and harsh toilet paper.
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| *Keeping the anus dry and hygienic.
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| *When using Analpram (cream) do not use the dispenser which can injure the area. Instead use a finger to insert a pea size amount of cream.
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| *[[Carmex]] lip ointment (the version <i>without</i> sunscreen-protection chemicals) also helps and is much less expensive than Analpram ($70.00 small tube).
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| ==Treatment== | | == [[Anal fissure natural history, complications and prognosis|Natural History, Complications and Prognosis]] == |
| For many years up until 1995, customary treatment included warm baths, topical anesthetics, stool bulking agents, mechanical anal stretching, and, sometimes, surgery.<ref name="new"/> In 1995, doctors began using nitroglycerine cream (topical 1 percent isosorbide dinitrate) but found it less acceptable for long-term use due to patients developing a tolerance to the drug.<ref name="new"/> In 1998, Italian researchers reported injecting [[botulinum toxin]] into the anal sphincter to promote healing by relieving anal spasm through relaxation of the muscle.<ref name="new"/>
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| ===Symptomatic=== | | == [[Anal fissure diagnosis|Diagnosis]] == |
| Most anal fissures are shallow or superficial (less than a quarter of inch or 0.64 cm deep). These fissures self-heal within a couple of weeks. Furthermore, treatment used for [[hemorrhoid]] such as eating a high-fiber diet, using stool softener, taking pain killer and having a [[sitz bath]] can help.
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| ===Pediatric===
| | [[Anal fissure history and symptoms|History and Symptoms]] | [[Anal fissure physical examination|Physical Examination]] | [[Anal fissure laboratory findings|Laboratory Findings]] | [[Anal fissure abdominal x ray|Abdominal X Ray]] | [[Anal fissure CT|CT]] | [[Anal fissure MRI|MRI]] | [[Anal fissure ultrasound|Ultrasound]] | [[Anal fissure other imaging findings|Other Imaging Findings]] | [[Anal fissure other diagnostic studies|Other Diagnostic Studies]] |
| Anal fissures in infants usually self-heal without anything more than frequently changing diapers and treating constipation if the cause. | |
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| ===Chemical sphincterotomy=== | | == Treatment == |
| Painful deep chronic fissures, on the other hand, will not heal because of poor blood supply caused by sphincter spasm. Traditionally surgical operations were required which are both painful and associated with various longterm complications, particularly incontinence in a small proportion of cases. Local application of medications to relax the sphincter muscle, thus allowing the healing to proceed, was first proposed in 1994 with [[nitroglycerine]] ointment,<!--
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| --><ref>{{cite journal |author=Loder P, Kamm M, Nicholls R, Phillips R |title='Reversible chemical sphincterotomy' by local application of glyceryl trinitrate |journal=Br J Surg |volume=81 |issue=9 |pages=1386-9 |year=1994 |id=PMID 7953427}}</ref><!--
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| --><ref>{{cite journal |author=Watson S, Kamm M, Nicholls R, Phillips R |title=Topical glyceryl trinitrate in the treatment of chronic anal fissure |journal=Br J Surg |volume=83 |issue=6 |pages=771-5 |year=1996 |id=PMID 8696736}}</ref><!--
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| --><ref>{{cite journal | author = Simpson J, Lund J, Thompson R, Kapila L, Scholefield J | title = The use of glyceryl trinitrate (GTN) in the treatment of chronic anal fissure in children. | journal = Med Sci Monit | volume = 9 | issue = 10 | pages = PI123-6 | year = 2003 | id = PMID 14523338}}</ref>
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| in 1999 with [[nifedipine]] ointment,<!--
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| --><ref>{{cite journal |author=Antropoli C, Perrotti P, Rubino M, Martino A, De Stefano G, Migliore G, Antropoli M, Piazza P |title=Nifedipine for local use in conservative treatment of anal fissures: preliminary results of a multicenter study |journal=Dis Colon Rectum |volume=42 |issue=8 |pages=1011-5 |year=1999 |id=PMID 10458123}}</ref><!--
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| --><ref>{{cite journal |author=Katsinelos P, Kountouras J, Paroutoglou G, Beltsis A, Chatzimavroudis G, Zavos C, Katsinelos T, Papaziogas B |title=Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity |journal=World J Gastroenterol |volume=12 |issue=38 |pages=6203-6 |year=2006 |id=PMID 17036396| url=http://www.wjgnet.com/1007-9327/12/6203.asp}}</ref>
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| and the following year with topical [[diltiazem]].<!-- --><ref>{{cite journal |author=Carapeti E, Kamm M, Phillips R |title=Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects |journal=Dis. Colon Rectum |volume=43 |issue=10 |pages=1359-62 |year=2000 |pmid=11052511}}</ref>
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| Branded preparations are now available of topical nitroglycerine ointment (Rectogesic as 0.2% in Australia and 0.4% in UK) and diltiazem 2% (Anoheal in UK although still in Phase III development).
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| [[Botulinum toxin]] injection, administered by colorectal surgeons, can also be used to relax the sphincter muscle and its use for this condition was first investigated in 1993.<!-- | | [[Anal fissure medical therapy|Medical Therapy]] | [[Anal fissure surgery|Surgery]] | [[Anal fissure primary prevention|Primary Prevention]] | [[Anal fissure secondary prevention|Secondary Prevention]] | [[Anal fissure cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Anal fissure future or investigational therapies|Future or Investigational Therapies]] |
| --><ref>{{cite journal |author=Jost W, Schimrigk K |title=Use of botulinum toxin in anal fissure |journal=Dis Colon Rectum |volume=36 |issue=10 |pages=974 |year=1993 |id=PMID 8404394}}</ref>
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| Combination of medical therapies may offer up to 98% cure rates,<!--
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| --><ref>{{cite journal |author=Tranqui P, Trottier D, Victor C, Freeman J |title=Nonsurgical treatment of chronic anal fissure: nitroglycerin and dilatation versus nifedipine and botulinum toxin |journal=Canadian journal of surgery. Journal canadien de chirurgie |volume=49 |issue=1 |pages=41-5 |year=2006 |pmid=16524142 |url=http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-49/issue-1/pdf/pg41.pdf |format=PDF}}</ref>
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| These medical treatments are used as first line therapy in treating chronic anal fissures,<!--
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| --><ref>{{cite journal |author=Haq Z, Rahman M, Chowdhury R, Baten M, Khatun M |title=Chemical sphincterotomy--first line of treatment for chronic anal fissure |journal=Mymensingh Med J |volume=14 |issue=1 |pages=88-90 |year=2005 |id=PMID 15695964}}</ref>
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| although a [[Cochrane Collaboration]] review of published research has questioned the effectiveness of medical treatments compared to surgery.<!--
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| --><ref>{{cite journal |author=Nelson R |title=Non surgical therapy for anal fissure |journal=Cochrane database of systematic reviews (Online) |volume= |issue=4 |pages=CD003431 |year=2006 |pmid=17054170}}</ref>
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| ===Surgical sphincterotomy=== | | == Case Studies == |
| Surgical intervention may be required for persisting deep anal fissures unresponsive to the above conservative measures. Procedures include:
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| *Internal lateral sphincterotomy or [[excision|excising]] a portion of the sphincter
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| * Anal dilation or stretching of the anal canal is no longer recommended because of the unacceptably high incidence of [[fecal incontinence]].<ref>{{cite journal |author=Kotlarewsky M, Freeman JB, Cameron W, Grimard LJ |title=Anal intraepithelial dysplasia and squamous carcinoma in immunosuppressed patients |journal=Canadian journal of surgery. Journal canadien de chirurgie |volume=44 |issue=6 |pages=450-4 |year=2001 |pmid=11764880 |doi= |url=http://www.cma.ca/multimedia/staticContent/HTML/N0/l2/cjs/vol-44/issue-6/pdf/pg450.pdf |format=PDF}}</ref> In addition, anal stretching can increase the rate of flatus incontinence.<ref>{{cite journal |author=Sadovsky R |title=Diagnosis and management of patients with anal fissures - Tips from Other Journals |journal=American Family Physician |year=2003 |month=1 April |volume=67 | issue=7 |pages=1608 |url=http://findarticles.com/p/articles/mi_m3225/is_7_67/ai_99410474 |format=Reprint}}</ref>
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| Despite the high success rate of these surgical procedures (~95%), there are potential side effects, which include: risks from [[anesthesia]], [[infection]] and anal leakage ([[fecal incontinence]]).
| | : [[Anal fissure case study one|Case #1]] |
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| ==References==
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| {{Reflist|2}}
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| ==External links==
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| * {{cite web|title=Anal Fissure Information | url=http://www.cafissure.com | accessdate=2007-11-02}}
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| * {{cite web|title=Anal Fissure Self Help Page | url=http://www.boardsailor.com/jack/af/ | accessdate=2007-03-17}}
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| * {{cite web | title=Anal Fissure | work=Hemorrhoids In Plain English | url=http://www.hemorrhoidsinplainenglish.com/anorectal/anal-fissure.htm | accessmonthday=December 15 | accessyear=2005}}
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| * {{cite web | title=Anal Fissure | work=McKinley Health Center | url=http://www.mckinley.uiuc.edu/Handouts/anal_fissure.html | accessmonthday=December 15 | accessyear=2005}}
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| * {{cite web | title=MedicineNet | work=Anal Fissure | url=http://www.medicinenet.com/Anal_Fissure/article.htm | accessmonthday=December 15 | accessyear=2005}}
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| * {{cite web | title=What are Anal Fissures? | work=Cellegy Pharmaceuticals | url=http://www.cellegy.com/science/anal-fissures.html | accessmonthday=December 15 | accessyear=2005}}
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| *[http:////www.wikisurgery.com/index.php?title=Anal-fissure-lateral-sphincterotomy-Operationscript Anal fissure and lateral sphincterotomy:Operation Script on Wikisurgery].
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| *[http://www.wikisurgery.com/index.php?title=Anal-fissure-lateral-sphincterotomy-PatientInformation Anal fissure and lateral sphincterotomy:Information for patients on Wikisurgery].
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| {{Gastroenterology}} | | {{Gastroenterology}} |
| [[Category:Gastroenterology]]
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| [[Category:Proctology]]
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| [[de:Analfissur]] | | [[de:Analfissur]] |
| [[fr:Fissure anale]] | | [[fr:Fissure anale]] |
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