anal%20fissure
ANAL FISSURE
An anal fissure is a disruption of the skin at the distal anal canal.
Most fissures are seen by separating the buttocks with opposing traction of the thumbs.
Majority of fissures are located in the posterior midline of the anus.
Acute fissures are simple splits or cracks in the anoderm while chronic fissures may show secondary changes eg sentinel tag, hypertrophied anal papilla, rolled edges, fibrosis of the edges or deep ulceration with exposure of the underlying internal anal sphincter muscle within the fissure's base.

Diagnosis

Physical exam findings confirm the diagnosis of an anal fissure:

  • An anal fissure is a disruption of the skin at the distal anal canal
  • Most fissures are seen by separating the buttocks with opposing traction of the thumbs
    • A digital examination causes severe pain and should be deferred in most cases
    • If a sentinel skin tag is seen, a physician should be alerted to the possible presence of a fissure, even if there is none readily apparent
  • Majority of fissures are located in the posterior midline of the anus
    • About 10% are anteriorly located and a small fraction of patients (2-3%) may have both anterior and posterior fissures
  • Fissures spotted off the midline should lead to a suspicion of underlying diseases, eg Crohn’s disease, cancer, human immunodeficiency virus (HIV)/acute immune deficiency syndrome (AIDS), tuberculosis (TB), syphilis
  • Anal fissures may often be misdiagnosed as hemorrhoids by primary care providers

Laboratory Tests

  • In cases when the fissure is not readily visualized, anoscopy may often be deferred and treatment initiated based on symptoms alone
  • Off-the-midline, multiple, or non-healing fissures usually require further evaluation, usually with examination under anesthesia and other studies eg biopsy, cultures, sigmoidoscopy or colonoscopy
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