Anal fissure: Difference between revisions
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==Background== | <languages/> | ||
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==Background== <!--T:1--> | |||
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[[File:Human anus-en.png|thumb|Anatomy of the anus.]] | |||
[[File:Gynecological diagnosis (1910) (14798113703).jpg|thumb|Anatomy of anal fissure.]] | |||
*Superficial linear tear of anal canal from at/below dentate line to anal verge | *Superficial linear tear of anal canal from at/below dentate line to anal verge | ||
**May be due to passage of hard stool, frequent diarrhea, or abuse | **May be due to passage of hard stool, frequent diarrhea, or abuse | ||
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**Non-healing fissure or one not located in midline suggests alternative diagnosis (e.g. Crohn's, malignancy) | **Non-healing fissure or one not located in midline suggests alternative diagnosis (e.g. Crohn's, malignancy) | ||
==Clinical Findings== | |||
==Clinical Findings== <!--T:3--> | |||
<!--T:4--> | |||
[[File:Anal fissure 2.jpg|thumb|Close up photo of anal fissure (at red arrow).]] | |||
*Acute sharp, cutting pain most severe during and immediately after bowel movement | *Acute sharp, cutting pain most severe during and immediately after bowel movement | ||
**Subsides between bowel movements (distinguishes fissure from other anorectal disease) | **Subsides between bowel movements (distinguishes fissure from other anorectal disease) | ||
*Bright red [[rectal bleeding]], small in quantity (usually noticed only on toilet paper) | *Bright red [[Special:MyLanguage/rectal bleeding|rectal bleeding]], small in quantity (usually noticed only on toilet paper) | ||
*Lateral to anus often indicates associated systemic illness such as [[Crohn's]], [[HIV]], [[leukemia]], [[TB]], [[syphilis]] | *Lateral to anus often indicates associated systemic illness such as [[Special:MyLanguage/Crohn's|Crohn's]], [[Special:MyLanguage/HIV|HIV]], [[Special:MyLanguage/leukemia|leukemia]], [[Special:MyLanguage/TB|TB]], [[Special:MyLanguage/syphilis|syphilis]] | ||
==Differential Diagnosis== <!--T:5--> | |||
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{{Anorectal DDX}} | |||
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{{Lower GI bleeding DDX}} | |||
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==Evaluation== <!--T:6--> | |||
===Workup=== <!--T:7--> | |||
<!--T:8--> | |||
*Typically clinical (no studies needed) | |||
===Diagnosis=== <!--T:9--> | |||
<!--T:10--> | |||
*Having patient bear down may make fissure more noticable | *Having patient bear down may make fissure more noticable | ||
*Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity | *Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity | ||
**Often misdiagnosed as an external [[hemorrhoid]] | **Often misdiagnosed as an external [[Special:MyLanguage/hemorrhoid|hemorrhoid]] | ||
== | ==Management== <!--T:11--> | ||
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*Warm sitz baths 15 min TID-QID and after each bowel movement | *Warm sitz baths 15 min TID-QID and after each bowel movement | ||
**Provides symptomatic relief by improving anal blood flow and relieves anal sphincter spasm | **Provides symptomatic relief by improving anal blood flow and relieves anal sphincter spasm | ||
*Topicals | *Topicals | ||
**Pain control with [[lidocaine]] | **Pain control with [[Special:MyLanguage/lidocaine|lidocaine]] | ||
**Vasodilators such as [[nitroglycerin]] or [[nifedipine]] ointment | **Vasodilators such as [[Special:MyLanguage/nitroglycerin|nitroglycerin]] or [[Special:MyLanguage/nifedipine|nifedipine]] ointment | ||
**[[Hydrocortisone]] | **[[Special:MyLanguage/Hydrocortisone|Hydrocortisone]] | ||
*High-fiber diet | *High-fiber diet | ||
**Prevents stricture formation by providing a bulky stool | **Prevents stricture formation by providing a bulky stool | ||
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*Surgical referral indicated if healing does not occur in a reasonable amount of time | *Surgical referral indicated if healing does not occur in a reasonable amount of time | ||
==Disposition== | ==Complications== <!--T:13--> | ||
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*[[Special:MyLanguage/Anorectal abscess|Anorectal abscess]] | |||
==Disposition== <!--T:15--> | |||
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*Most patients can be managed medically and discharged with outpatient follow-up | *Most patients can be managed medically and discharged with outpatient follow-up | ||
==References== | ==See Also== <!--T:17--> | ||
<!--T:18--> | |||
*[[Special:MyLanguage/Anorectal Disorders|Anorectal Disorders]] | |||
==External Links== <!--T:19--> | |||
<!--T:20--> | |||
*[https://www.merckmanuals.com/professional/gastrointestinal-disorders/anorectal-disorders/anal-fissure?query=anal%20fissure Merk Manual - Anal Fissure] | |||
*[https://emottawablog.com/2019/10/the-bottom-line-hemorrhoids-and-anal-fissures-in-the-ed/ EM Ottawa - Hemorrhoids and Anal Fissures in the ED] | |||
==References== <!--T:21--> | |||
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<references/> | <references/> | ||
<!--T:23--> | |||
[[Category:GI]] | [[Category:GI]] | ||
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Latest revision as of 20:29, 6 January 2026
Background
_(14798113703).jpg)
- Superficial linear tear of anal canal from at/below dentate line to anal verge
- May be due to passage of hard stool, frequent diarrhea, or abuse
- Most common cause of painful rectal bleeding
- In >90% of cases anal fissures occur in the midline posteriorly
- Non-healing fissure or one not located in midline suggests alternative diagnosis (e.g. Crohn's, malignancy)
Clinical Findings
- Acute sharp, cutting pain most severe during and immediately after bowel movement
- Subsides between bowel movements (distinguishes fissure from other anorectal disease)
- Bright red rectal bleeding, small in quantity (usually noticed only on toilet paper)
- Lateral to anus often indicates associated systemic illness such as Crohn's, HIV, leukemia, TB, syphilis
Differential Diagnosis
Anorectal Disorders
- Anal fissure
- Anal fistula
- Anal malignancy
- Anal tags
- Anorectal abscess
- Coccydynia
- Colorectal malignancy
- Condyloma acuminata
- Constipation
- Crohn's disease
- Cryptitis
- GC/Chlamydia
- Fecal impaction
- Hemorrhoids
- Levator ani syndrome
- Pedunculated polyp
- Pilonidal cyst
- Proctalgia fugax
- Proctitis
- Pruritus ani
- Enterobius (pinworms)
- Rectal foreign body
- Rectal prolapse
- Syphilitic fissure
Non-GI Look-a-Likes
Undifferentiated lower gastrointestinal bleeding
- Upper GI Bleeding
- Diverticular disease
- Vascular ectasia / angiodysplasia
- Inflammatory bowel disease
- Infectious colitis
- Mesenteric Ischemia / ischemic colitis
- Meckel's diverticulum
- Colorectal cancer / polyps
- Hemorrhoids
- Aortoenteric fistula
- Nearly 100% mortality if untreated
- Consider in patients with gastrointestinal bleeding and known abdominal aortic aneurysms or aortic grafts
- Rectal foreign body
- Rectal ulcer (HIV, Syphilis, STI)
- Anal fissure
Evaluation
Workup
- Typically clinical (no studies needed)
Diagnosis
- Having patient bear down may make fissure more noticable
- Sentinel pile, located at distal end of fissure, along with deep ulcer suggests chronicity
- Often misdiagnosed as an external hemorrhoid
Management
- Warm sitz baths 15 min TID-QID and after each bowel movement
- Provides symptomatic relief by improving anal blood flow and relieves anal sphincter spasm
- Topicals
- Pain control with lidocaine
- Vasodilators such as nitroglycerin or nifedipine ointment
- Hydrocortisone
- High-fiber diet
- Prevents stricture formation by providing a bulky stool
- Meticulous anal hygiene is imperative; after defecation anus must be cleaned thoroughly
- Surgical referral indicated if healing does not occur in a reasonable amount of time
Complications
Disposition
- Most patients can be managed medically and discharged with outpatient follow-up
See Also
External Links