Investigation Report and Case Sheet of Patient

Anal Fissures may present with rectal pain described as burning, cutting, or tearing that occurs with bowel movements. Spasm of the anus is very suggestive for an anal tissure. A history of constipation or passage of hard stools, but blood usually is not mixed into stool and is present only in a small Bleeding.

Anal Fistula may complain of recurrent malodorous perianal drainage, prutitus, recurrent abscesses, fever, or perianal pain due to an occluded tract. Patients may report a recent perianal or buttock abscess. Pain occurs with sitting, moving, defecating, and even coughing. It usually is throbbing in quality and is constant throughout the day. Pain occasionally resolves spontaneously with reopening of a tract or formation of a new outflow tract.

Physical Examination

The physical examination of patients with fistulas or fissures begins by optimizing patient placement; place the patient in the left lateral decubitus position with knees drawn up toward the chest. Examine the patient carefully to help avoid inflicting further pain or sphincter spasm. Rectal examination is generally difficult to tolerate because of sphincter spasm and pain. Examination may be facilitated by applicaton of topical anesthetic, such as lidocaine jelly, before digital rectal examination (DRE); however, a DRE may not be tolerated by some patients. Most fissures are visible externally when the buttocks are gently spread apart.Having the patient bear down as if having a bowel movement may also help visualize an anal fissure. Acute fissures appear similar to laceration, while a chronic fissure may be accompanied by external skin tags distally and hypertrophied anal papillae proximally. Most tears are found in the with chronic fissures, the classic fissure triad may be seen, as follows:

Deep ulcer

Sentinet pile, which forms the base of the fissure becomes edematous and hypertrophic (a resolving sentinet pile can result in a permanent skin tag or may become associated with a fistulous tract)

Entraged anal papillae at dentate line, only seen in the OR under general anesthesia or if prolapsed

Bidigital rectal examination in a patient with a fistula-in-ano may reveal an indurated tract or cord. A fistula can be identified by small circles of granulation tissue, which exude pus when compressed if tissue is patient. A fistulous tract that opens internally can be visualized with the aid of an anoscope. Inguinal lymph nodes may be enlarged and painful.

If an abscess is also present with an anal fistula, cardinal signs of inflammation, rubor, dolor, calor, and tumor (eg. Erythema, pain, increased temperature, edema) may be found.

Complications

Constipation or fecal impaction may occur. The pain from an anal fissure can be so overwhelming that it discourages people from defecating. Acute fissures can become chronic, and sentinel pile can result. A Permanent skin tag can result, and fistulas may form.

The following complications may occur with surgical intervention:

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Approach Considerations

Diagnosis of an anal fissure is primarily based on the history and physical examination. No specific testing is needed for diagnosing anal fissures unless atypical or multiple fissures are present, suggesting either an infectious or other etiology.

Evaluation of an anal fistula depends on the clinical status of the patient. If a concurrent abscess is present, and the location and size is not well characterized, advanced imaging may be needed. Blood work should be reserved for patients with clinical signs of sepsis or those who appear toxic. Wound culture may also be indicated if there is concern for possible infectious etiologies such as syphilis or HIV infection. If clinically warranted, a workup for other etiologies such as Crohn disease may be indicated.

If the exhent of the fistula is not well characterized by physical examination, advanced diagnostics may be indicated to evaluate the anatomy of complex tistula.

Anal Fistula

Treatment of anal fistulas depends on ( 1 ) the location of the fistula, ( 2 ) evidence of sepsis or a large abscess, or ( 3 ) worrisome findings on physical examination. If an abscess is present, drainage is indicated. Intravenous antibiotics, antipyretics, and analgesics are provided as needed. However, simple rectal abscesses do not typically need antibiotics. If the patient also has sepsis, intravenous fluids or a pressor may be necessary. Depending on the presence of systemic symptoms and the condition of the patient, surgery may be necessary.

For anal fistulas, outpatient follow-up with a surgeon is indicated if consultation did not take place at the time of presentation. Surgical therapy is often indicated for healing of an anal fistula. The surgical approach is dependent on whether the fistula is simple or complex, as well as the risk of complications such as incontinence. A gastroenterologist should be consulted if inflammatory bowel disease is suspected. Asymptomatic anal fistulas from Crohn disease are not managed by surgery. However, if the patient is symptomatic, surgical management should be considered. Antibiotics should be reserved for those with overlying cellulitis or those with sepsis. Otherwise, symptomatic treatment with analgesics should be considered.

Surgical Treatment of Anal Fistulas

For simple anal fistulas, fistulotomy with or without marsupialization is recommended. In the presence of an abscess with anal fistula, incision and drainage along with fistulotomy may be considered. This is associated with decreased incurrence but increased risk of continence disturbance. Fibrin glue has also been studied, with the advantage of less risk of incontinence. However, success rates have been reported lower than those for fistulotomy for complex fistulas, debridement and fibrin glue or fistula plug may be used Although it has a relatively low success rate, recent guidelines suggest that fibrin glue may be used as first line therapy. Likewise, variable success has been reported with fistula plugs. One small trail described a success rate of 72.7% with the use of the Gore Bio-A fistula plug Endoanal advancement flaps also have variable success rates for the treatment of complex fistulas.

Ligation of intersphincteric fistula tract (LIFT) has also been described, with long term success rates (> 12 months) of 62%. In this small study, fistula tract lengths greater than 3 cm were noted to have a higher rate of failure with LIFT (odds ratio, 0.55; 95% confidence interval, 0.34-0.88). Investigated the healing rate after operations for anal fistulas in New England Colorectal surgery practices. They conducted a retrospective review of a prospectively collected database regarding patients operated on for anal fistulas. The treating surgeon determined fistula classification, surgical intervention, continence scores, and heating. Sixteen surgeons submitted data from 240 operations for fistula with curative intent. The healing rates of fistulotomy, advancement flap, and fistula plugs at 3 months were 94%. 60% and 20%, respectively. The healing rate of the ligation of intersphincteric fistula tract procedure at 3 months was 79%. Hospitals that perfomed more ligation of intersphincteric fistula tract procedures had higher healing rates at 3 months. In some cases, staged surgery is needed to repair an anala fistula

Anal Fissure

Anal Fissures can cause a vicious cycle in which the patient, in anticipation of pain associated with bowel movement, resists the urge to defecate, causing stools to become larger and harder, resulting in more pain with defecation. Treatment should be focused on breaking this cycle to allow healing. If the patient is having a great deal of pain, a topical anesthetic may be applied. Diet modification to soften stools is also indicated in patients with anal fissures. Patients should increase fruits, vegetables and soluble and insoluble fibers in their diets and increase fluid intake to treat the acute phase and to prevent recurrence. Bulking agents such as psyllium may be prescribed. Approximately half of all anal fissures heat with nonoperative therapy within 2 – 4 weeks.



Use the WASH regimen in treatment of anal fissures, as follows:

Medications may also be prescribed for anal fissures, such as topical nitrates, calcium channel blockers, and onabotulinumtoxina injections, and are considered first time therapy. These medications reduce anal sphincter tone or vasodilate, which, in turn, increases anodermal blood flow. When conservative Treatment fails, surgical therapy may be option to treat anal fissures.

Historically, surgical therapy was common for the treatment of anal fissures and is considered superior to nonoperative therapies. However, due to the risk of complications, including incontinence, surgical therapy is often reserved when conservative treatment fails to heal and fissures.

Surgical Treatment of Chronic Anal Fissures

Chronic anal fissures frequently require surgical treatment. Surgical procedures may involve lateral internal sphincterotomy (LIS), anal dilation, or fissurectomy.

LIS is considered the treatment of choice for chronic anal fissure and can be performed either opened or closed. It reduces the hypertonia of the internal anal sphincter, increases anodermal blood flow, decreases pain, and allows the fissure to heal. However, traditional LIS has been associated with relatively high rates of incontinence.

Other surgical techniques have been decribed, including a more tailored approach, which showed lower rates of complications but higher rates of treatment failure. LIS has been shown to have a higher rate of cure than anal dilation. Data for subcutaneous fissurectomy with anal advancement flap are limited, but promising.

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