Anal fissures are very small lacerations or ulcerative lesions, elliptical or linear in shape and benign in nature, that appear on the external part of the anal canal.
The anus, representing the end of the digestive tract, is a tube of approximately 1.5 to 2 cm, which connects in its upper part with the lower part of the rectum and below with the skin of that region.
In medicine, the anal canal or canal is defined in two ways even though we refer to the same organ:
· The anatomical anal canal or canal: portion of the digestive tube that extends from the dentate line (transition of the mucosa to squamous epithelium) to the edge of the anus that continues with the skin of the perineum.
· The surgical anal canal or canal: it begins in the anorectal ring which is located above the dentate line and also extends to the edge of the anus.
This pathology occurs with the same frequency in both men and women, but it tends to affect young people and middle-aged adults more.
In general, benign anal fissures are unique and will originate in the midline of the anus, for this reason, the presence of multiple fissures or in other locations than the one mentioned above, should make us think of other diseases such as ulcerative colitis, Crohn's disease, tuberculosis, syphilis, or human immunodeficiency syndrome (HIV).
One of the possible benign causes of anal fissure is constipation, since the passage of hard stool through the anal canal causes a tear in one of the folds of the anus and causes a laceration. It is also believed that because the posterior region of the anal canal has less blood supply, it is much more prone to fissures.
On the other hand, it must be taken into account that fissure infections play an important role in their pathophysiology, because they predispose to the chronicity of fissures, preventing them from scarring and healing. The infection of the fissures is mainly due to the fact that the epithelial cells are exposed and in contact with a large amount of bacteria that are found in the anal area and feces.
Symptoms of an anal fissure
· Intense pain when evacuating.
· Pain after bowel movements that can last up to several hours.
· Bright red blood in stool or on toilet paper after you have a bowel movement.
· Itching or irritation around the anus.
· Visible crack in the skin around the anus.
· Small lump or skin tag near the anal fissure.
The diagnosis of anal fissure is made with a simple anal examination, which is carried out by the specialist in the colon, rectum and anus. During this evaluation, the doctor will see a small fissure or tear located in the midline. When there is more than one fissure and they are not located in the midline, a differential diagnosis should be carried out among other pathologies previously described.
Treatment of anal fissure
After the differential diagnosis, conservative treatment is followed for at least 2 weeks.
If the symptoms resolve, the patient is kept on a fiber-rich diet and if they persist, they are referred for evaluation and surgical treatment.
1. Conservative treatment: it is based on the theory of constipation as a cause. It consists of the patient improving their lifestyle, by this we mean significant changes in the individual's diet. You should increase the intake of fruits, vegetables and vegetables, whole wheat bread (foods rich in fiber) and decrease the consumption of white bread, flours, sausages and fats, you should also implement the consumption of dietary fiber supplements, softening laxatives, baths of hot seat, nitroglycerin ointment and use of ointments with local anesthetic or hydrocortisone and general analgesics.
These measures produce a significant symptomatic improvement in the first week, healing the fissures completely between 2 and 4 weeks. Although improvement is not always evident.
2. Invasive treatment: The surgical treatment of choice is the internal lateral sphincterotomy. The intervention consists of the controlled section of the internal anal sphincter that eliminates the hypertonia, making the pain disappear and achieving the healing of the fissure in a few days.
What happens when the muscle fibers are cut is that the sphincter will decrease its tension and in this way there will not be the same contraction that was previously causing the fissure.
Other techniques such as anal dilation are no longer used or are done in specific cases.
The American Society of Colon and Rectal Surgeons establishes the internal lateral sphincterotomy as the "Gold standard" treatment of anal fissure, that is, as the treatment of choice.
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