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Anal Fissure, Emergency Medicine

Basics

Description

- Hard stool passes and "cuts"Ł anoderm - Linear tear extends from dentate line to anoderm: - Posterior midline 95% - Anterior midline 5% - Externally: Forms skin tag or sentinel pile - Internally: Forms hypertrophied anal papilla - Chronic fissure may reveal fibers of internal sphincter with sentinel pile.

  • Hard stool passes and "cuts"Ł anoderm
  • Linear tear extends from dentate line to anoderm:Posterior midline 95%Anterior midline 5%Externally: Forms skin tag or sentinel pileInternally: Forms hypertrophied anal papillaChronic fissure may reveal fibers of internal sphincter with sentinel pile.

Etiology

  • Stress or an overly tight anal sphincter leads to local ischemia of posterior anoderm.
  • Diarrhea or hard bowel movement tears anoderm.
  • Local trauma from anal intercourse or sexual abuse may be the cause.
  • Lateral fissures indicate underlying causative systemic disease:Crohns diseaseAnal cancerLeukemiaSyphilisPrevious anal surgery

Diagnosis

Signs and Symptoms

  • Bright red blood per rectum usually on toilet paper
  • Sharp, cutting, throbbing or burning pain with bowel movement:
  • Constipation; unable to pass stool owing to pain:Hard, nondeformable stools

History

  • Passage of hard stool or constipation
  • Episode(s) of diarrhea
  • Bright red blood on toilet paper

Physical Exam

Anal exam: á

  • Gently retract buttocks and have patient bear down to visualize the fissure.
  • Severe pain usually prevents a manual or digital exam:Use lidocaine jelly or ELA-Max5, a topical lidocaine ointment, before attempting digital rectal exam.Need to exclude abscess or tumor

A clear test tube may be used as an anoscope to visualize the anal canal/fissure. á

Essential Workup

Careful rectal exam á

Diagnosis Tests & Interpretation

Lab

Hematocrit if severe bleeding by history á

Imaging

CT pelvis: á

  • To exclude anal rectal abscess/tumor if palpable mass on rectal exam

Differential Diagnosis

  • Crohns disease
  • Chronic ulcerative colitis
  • Anorectal carcinoma
  • Perirectal abscess
  • Thrombosed hemorrhoid
  • Sexual abuse
  • TB
  • Syphilis
  • Lymphoma
  • Leukemia
  • Previous anal surgery

Treatment

Pre-Hospital

Establish IV access for patients with significant rectal bleeding. á

Initial Stabilization/Therapy

Administer pain medications for patients with significant pain. á

Ed Treatment/Procedures

  • IV/IM/PO pain medications:NSAIDsAcetaminophenMuscle relaxants to relieve sphincter spasm:CyclobenzaprineDiazepamDiltiazem 2% ointmentNifedipine ointment 0.3%
  • Topical anesthetics:ELA-Max5Lidocaine jelly 2%
  • Sitz baths (with warm water) to relieve sphincter spasm

Diet

  • High-fiber diet instruction:Fiber/bran: 20 g/dPsyllium seeds (Metamucil or Konsyl): 1-2 tsp (peds: 0.25-1 tsp/d) PO q24h
  • Encourage consumption of 10-12 oz glasses of water per day.

Medication

  • Cyclobenzaprine (Flexeril): 10 mg (peds: Not indicated) PO TID
  • Diazepam (Valium): 5 mg (peds: 0.12-0.8 mg/kg/d) PO TID PRN for spasm
  • Diltiazem 2% ointment: Apply to fissure BID
  • Docusate sodium (Colace): 50-200 mg (peds: younger than 3 yr, 10-40 mg/d; 3-6 yr, 20-60 mg/d; 6-12 yr, 40-150 mg/d) PO q12h
  • ELA-Max5 (5% lidocaine anorectal cream): Apply to perianal area q4h PRN pain (pediatric dose: Not for those younger than 12 yr)
  • Ibuprofen: 400-600 mg (peds: 40 mg/kg/d) PO q6h
  • Nifedipine ointment 0.3%: Apply to fissure TID with Q-tip (peds: Not indicated)
  • Nitroglycerin ointment 0.2%: Apply a small pea-sized dot to fissure BID-TID with cotton swab. (peds: Not indicated)

Follow-Up

Disposition

Admission Criteria

Severe abdominal pain/distention due to fecal impaction á

Discharge Criteria

  • Initial treatment is conservative therapy for acute anal fissures as an outpatient.
  • Operative referral for chronic fissures

Followup Recommendations

Colorectal or GI follow-up for patients with symptomatic fissures á

Pearls and Pitfalls

  • Perform a careful physical exam of rectal area to delineate fissures and exclude other pathology.
  • Provide combination of pain relief and muscle relaxants for patients with significant pain.
  • Provide discharge medications/instructions to prevent constipation.

Additional Reading

  • Herzig áDO, Lu áKC. Anal Fissure. Surg Clinf North Am. 2010;90(1):22-44.
  • Nelson áRL, Thomas áK, Morgan áJ, et al. Non-surgical Therapy for Anal Fissure. Cochrane Database Syst Rev. 2012;2:CD003431.
  • Orsay áC, Rakinic áJ. Practice parameters for the management of anal fissures (revised). Dis Colon Rectum. 2004;47:2003-2007.
  • Rakinic áJ. Anal fissure. Clin Colon Rectal Surg. 2007;20(2):133-138.

See Also (Topic, Algorithm, Electronic Media Element)

  • Hemorrhoid
  • Perirectal Abscess

Codes

ICD9

565.0 Anal fissure á

ICD10

  • K60.0 Acute anal fissure
  • K60.1 Chronic anal fissure
  • K60.2 Anal fissure, unspecified

SNOMED

  • 30037006 Anal fissure (disorder)
  • 197152000 Chronic anal fissure (disorder)
  • 197151007 Acute anal fissure (disorder)