Anal fissure overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Amandeep Singh M.D.[2]
Overview
Historical Perspective
Classification
Anal fissures can be divided into primary and secondary anal fissures based on etiology, posterior and anterior anal fissures based on location, and acute and chronic anal fissures based on the duration of symptoms.
Pathophysiology
The exact pathogenesis of anal fissure is not fully understood but constipation or anal trauma was supposed to instigate the fissure. It is understood that anal fissure is the result of either anal trauma (by hard stools/diarrhea), perfusion defects with ischemia caused due to increased anal pressures and decreased blood flow or increased anal sphincter tone. In 90% of the patients, anal fissures are found in posterior midline. A small tear is seen that extends from dentate line to anal verge due to ischemia/poor perfusion of the area by inferior rectal artery (during increased sphincter tone).
Causes
Anal fissure are caused due to severe and chronic constipation, watery diarrhea and Crohn's disease. Anal fissures are common in women after childbirth, and following constipation in infants. Other less common causes include tuberculosis, sarcoidosis, anal intercourse, HIV , Human papillomavirus, and syphilis.
Differentiating Anal fissure overview from Other Diseases
Anal fissure must be differentiated from other diseases that cause anal discomfort and pain with defecation such as hemorrhoids, rectal prolapse and perianal abscess, anal fistula and anal cancer.
Epidemiology and Demographics
The incidence of anal fissure is approximately 1100 per 100,000 individuals in US which is about 7.8% lifetime risk. The incodence is 30-50% in patients with Crohn's disease. Women in adolescence and child bearing group and males of middle aged group are commonly affected. Females are more affected than males.
Risk Factors
Screening
Natural History, Complications, and Prognosis
Natural History
Complications
Prognosis
Diagnosis
Diagnostic Criteria
History and Symptoms
Patients with anal fissure have a history of painful bowel movements and bleeding per rectum which can be seen as blood on tissue paper following a bowel movement. They usually have a history of constipation too but also some patients may report frequent episodes of watery diarrhea.They also have symptoms of painful defecation.Some patients may also have associated itching and irritation.