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.

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 disease
- Anal cancer
- Leukemia
- Syphilis
- Previous anal surgery

Diagnosis

Signs and Symptoms

Bright red blood per rectum usually on toilet paper
Sharp, cutting, throbbing or burning pain with bowel movement:
- May last for hours
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:
- NSAIDs
- Acetaminophen
- Muscle relaxants to relieve sphincter spasm:
  - Cyclobenzaprine
  - Diazepam
  - Diltiazem 2% ointment
  - Nifedipine ointment 0.3%
Topical anesthetics:
- ELA-Max5
- Lidocaine jelly 2%
Sitz baths (with warm water) to relieve sphincter spasm

Diet

High-fiber diet instruction:
- Fiber/bran: 20 g/d
- Psyllium 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.

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)

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