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Takashshurul Miqad

(Fissure in Ano)
Dr. MSM Shiffa
MD, BUMS, LLB, AAL
INTRODUCTION
Fissure is a linear or lngitudinal tear in the anal
canal extending from just below the dentate
line to the anal verge.

Most commonly in young and middle age


adults.

The cardinal symptom is pain during and for


minutes to hours following defecation.

Bright red blood is common


INTRODUCTION
Over 90% of anal fissures are located in the
posterior midline.

Almost all the rest located in the anterior


midline.

The acute fissure is a "mere crack" in the


anoderm.

Distal sentinel tag, a proximal hypertrophied


anal papilla, fibrotic edges, and exposed internal
sphincter fibres are features of chronicity
Etiology and Pathogenesis

The initiating factor is trauma, typically


overstretching of the anoderm by a large hard
stool.

The proposed explanation for the posterior midline


predominance is a lack of tissue support and
maximal stretching at this site.

Failure to heal is secondary to poor perfusion of the


anoderm in the posterior midline.

Posterior midline ischaemia is the result of arterial


anatomy and internal anal sphincter hypertonicity.
Etioloogy / Pathophysiology

Most anal fissures are caused by


stretching of the anal mucosa
beyond its capability. Various causes
of this fissure include:
Straining to defecate, especially if
the stool is hard and dry
Severe and chronic constipation
Severe and chronic diarrhea
Etioloogy / Pathophysiology
Crohn's disease and Ulcerative colitis
Anal sex
Anal stretching
Insertion of foreign objects into the
anus
Tight sphincter muscles
Excessive anal probing
asbab
Local trauma
Hard stool
Pregnancy
Delivery
Chron's disease
STUD
anal intercourse
Garam masala
Dry food
Mosam garmi
Amraze miq'ad
Safravi ishal
Excessive coldness
Clinical Mainfestations
The symptoms of anal fissure include:
Pain during, and even hours after,
defecation
Visible tear in the anus
Blood on the stool or on toilet paper
or toilet bowl
Constipation
Burning, possibly painful, itch
Alamat
Jiryane khoon
Shadeed dard
Severe sphincteric spasm
Pruritus ani
Sozish e miq'ad
Qabz
Sentinel pile/ skin tag
Treatment
Warm baths and a diet sufficiently high in
fibre to achieve soft bulky stools allows
approximately 50% of acute anal fissures
to heal within three weeks.

Stool softeners and fibre supplements are


reasonable additions.

Recurrence is common, in the range of 30


- 70%, but can be reduced to 15 - 20% by
maintaining a high fibre diet
Treatment
Chronic Fissure

Are unlikely to heal with warm baths and


a high fibre diet.

Internal Sphincterotomy : Lateral


internal sphincterotomy (LIS) achieves
healing in over 95% within several
weeks

Anal Dilatation
Medical Management
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. While waiting for
the fissure to heal, topical or suppository
containing anti-inflammatory agents and
local anesthetic can be used. Furthermore,
treatment used for hemorrhoid such as
eating a high-fiber diet, using stool
softener, taking pain killer and having a
sitting bath
Medical Management
Painful deep fissures, on the other
hand cut through the sphincter
muscle thus making it prone to
spasm, which exacerbates the fissure
and aborts the healing process.
Medications such as nitroglycerine
and nifedipine ointments can relax
the sphincter muscle
Medical Management
Surgical intervention may be required for
persisting deep anal fissures unresponsive
to the above conservative measures.
Procedures include:
Internal lateral sphincterotomy or excising
a portion of the sphincter
Anal dilation or stretching of the anal canal
is no longer recommended because of the
unacceptably high incidence of fecal
incontinence
Digital examination under
anaesthesia
Stool softener
Bulking agents
Local anaesthetic gel
Usool e ilaj
Izal e Sabab
Mulayyinat
Mushil
Correct the mizaj
Radiat
Mudammilat
Muhallilat
Habis ud dam
Daf e tafoon

Avoid
Hot & dry spicy food
Cold food
Take fibre, mucillagious food and fruit

Externally
Abzan
Nakhuna, baboona, gule teesu

If pain & burning sensations


Aabe kurfa
Aabe kithmi
Externally
Apply bone marrow + mom paste
Roghane banafsha
Roghane gul and anabussalab
Qurse kaharuba
Ith zamani
Ith muqil
Habe raswat
Maj muqil
Habe bawasir
Habe muqil
Ith mulayyin
Jawarish e kamooni mushil
Habe tanker
Sharbate anjeer