anal fissure
Introduction
Introduction to anal fissure The anal fissure is a small ulcer in the whole layer of the anal canal below the dentate line. Its direction is parallel to the longitudinal axis of the anal canal. It is about 0.5-1.0 cm long and has a fusiform or elliptical shape. It is difficult to heal and is an anal canal for young and middle-aged people. Common causes of severe pain. The superficial laceration of the anal canal can not be regarded as an anal fissure because it can heal quickly and is often asymptomatic. Anal fissure occurs in the middle of the anal canal. If there is an anal fissure on the side of the anal canal, or there are multiple clefts, it should be thought that it may be an early manifestation of intestinal inflammatory disease. basic knowledge The proportion of illness: 0.032% Susceptible people: no special people Mode of infection: non-infectious Complications: abscess
Cause
Anal fissure
Anatomical factors (30%):
The shallow part of the external anal canal sphincter forms an anal ligament in the back of the anus. It is hard and has poor elasticity. The levator ani muscle is mostly attached to both sides of the anal canal. Therefore, the front and back of the anal canal are not as strong as the two sides, and it is easy to damage. The rectal angle of the anal canal is formed with the rectum, and the pressure of the feces at the back of the anal canal is a factor that causes anal fissure.
Trauma (12%):
Chronic constipation patients, due to dry stool, excessive force during defecation, easy to damage the anal canal skin, repeated damage to the deep laceration and full-thickness skin, the formation of chronic infectious ulcers, it has been reported that constipation caused by anal fissure accounted for 14% ~ 24%, but constipation may also be the result of anal fissure, which is caused by the patient's fear of defecation. In addition, the birth injury can also cause anal fissure, which accounts for 3% to 9%. Frequent defecation during diarrhea and sensitive anal canal tightening Injury, repeated damage forms chronic infectious ulcers.
Infection (15%):
Chronic inflammation near the dentate line, such as anal sinusitis in the posterior midline, causes subcutaneous abscesses to spread down, causing chronic ulcers; the cause of difficult healing after anal canal injury is still unknown. Some people think that the main cause is injury. Infection, inflammatory cells can release collagenase during infection, preventing epithelial tissue regeneration and elongation.
Ischemia (10%):
Recently, it has been suggested that the median line of ischemia after anal canal is the reason why anal fissure occurs in this place, because the distal end of the anal canal is supplied by the inferior rectal artery. The blood vessel passes through the rectal fossa and divides the small anal sphincter to the mucosa. However, most of the posterior joints lack branches of the lower rectal artery (85%). The capillary morphology study also suggests that the capillaries inside the median sphincter are sparse. The anus is measured by laser Doppler flowmetry. The blood flow in the joint after the tube is less than in other quadrants. All of the above indicate that ischemia is the main factor in the pathogenesis of chronic anal fissure.
Acute anal fissure has a short onset period, reddish color, shallow bottom, fresh and rupture, no scar formation, long course of chronic anal fissure, repeated attacks, uneven bottom, frequent hypertrophy nipples on the upper end, and frequent outposts on the lower end. Generally referred to as the "triple sign of anal fissure", the outpost sputum is caused by lymphatic stagnation under the skin. It seems to be external sputum. Because it is seen after seeing this sputum and then seeing the rupture, it is helpful for diagnosis. Or splitting, in the advanced stage can also be complicated by perianal abscess and subcutaneous anal fistula.
The exact cause of anal fissure is still unknown. The following factors are related to the occurrence of anal fissure:
1. An anal canal stenosis congenital malformation, anal canal stenosis caused by trauma or surgery, anal fissure occurs when the dry stool is passed through.
2. Patients with internal sphincter anal fissure have abnormal internal sphincter hypercontraction. Reflex internal sphincter spasm is currently considered to be an important cause of anal fissure not easy to heal. Anal canal pressure in anal fissure patients is significantly higher than normal, up to 127.5± 42.2 kPa (956 ± 316 mmHg), while the normal person is only 86.3 ± 33.3 kPa (647 ± 250 mmHg), this high pressure can be restored to near normal after anal expansion treatment.
Pathogenesis
1. The anal fissure of the high-incidence site is often a crack. The vast majority occur in the midline of the anal canal. 355 cases of anal fissure are reported abroad, 89% are located in the posterior midline, 7% are located in the front center, and are located on both sides. The divisions each accounted for 2%, and the front center was more common among women.
2. Pathological acute anal fissure has a short onset time, color red, shallow bottom, fresh and rupture, no scar formation, chronic anal fissure has a long course, repeated attacks, uneven bottom, often with hypertrophy at the upper end, often at the lower end The outpost is generally called the "triple sign" of an anal fissure (Fig. 1). The outpost is caused by lymphatic deposits under the skin. It seems to be externally paralyzed. It is helpful for diagnosis because it sees the sputum after seeing it at the time of examination. Therefore, it is called episode sputum or fissure, and in the advanced stage, it can also be combined with perianal abscess and subcutaneous anal fistula.
3. Classification The classification of this disease has not been unified at home and abroad. There are two classifications and three stages of classification commonly used in clinical practice.
(1) Phase 2 classification:
1 early anal fissure (acute phase): fresh cracks, no chronic ulcers, less pain;
2 old anal fissure (chronic phase): the crack has formed a chronic ulcer, while the anal papillary hypertrophy, skin sag, etc., severe pain.
(2) Phase 3 classification:
1I stage anal fissure: short course of disease, clean bottom of the ulcer, soft, no complications;
2 stage II anal fissure: the bottom of the ulcer is grayish white, the edge is thick and irregular, the quality is hard or sneak, the anal canal elasticity is weakened, and there are complications;
3III anal fissure: ulcers such as stage 2 anal fissure, anal fibrosis, stenosis, and complications directly affect the severity of ulcers.
Prevention
Anal fissure prevention
1, anal fissure is a kind of pain in anal disease, and can be associated with many anal discomfort, therefore, the anal fissure should be important to prevent.
2, to keep the stool smooth, to develop the habit of regular bowel movements every day, found that when the stool is dry, should not blame the bowel movements, but to use warm salt water enema or open the plug to inject into the anus and laxative.
3, timely treatment of anal crypt inflammation, to prevent the formation of ulcers and subcutaneous fistula after infection.
4, when using the anoscope speculum for inspection, avoid using the speculum rough operation, damage the anal canal.
5, timely treatment of various diseases causing anal fissure, such as ulcerative colitis and other conditions, to prevent anal fissure.
6, to drink less, do not eat spicy food, food can not be too fine, to mix coarse and fine grain, vegetables and other fiber-rich foods as much as possible, so that the stool can be normal.
7, where there are perianal eczema, dermatitis, itching and other diseases should be actively treated to prevent perianal skin sclerosis, weakened elasticity and tear the anal canal skin.
8, for those with anal canal skin damage, should be actively treated to prevent ulcers due to infection.
9, for those with anal cryptitis and anal papillitis, should be cured as soon as possible to prevent anal fissure.
10, for anal rectal examination, avoid violent force, so as not to damage the anal canal.
Complication
Anal fissure complications Complications
If the treatment is not timely, the crack is repeatedly inflamed, and the infection develops subcutaneously into the anal margin, and a subcutaneous abscess and fistula are formed.
Symptom
Anal fissure symptoms common symptoms restless fatigue anal itching postpartum blood in the anus pain constipation blood defecation anal burning pus and anal fissure
Typical clinical manifestations of anal fissure patients are pain, constipation and blood in the stool.
1. Pain anal fissure can cause periodic pain due to defecation. This is the main symptom of anal fissure. When excreting, the fecal block stimulates the nerve endings of the ulcer surface, and immediately feels the burning pain of the anus, but the pain is relieved after a few minutes. This period is called intermittent pain period. Later, due to internal sphincter spasm, it will cause severe pain. This period lasts for half an hour to several hours, making the patient restless and unbearable until the sphincter fatigue, muscle relaxation, pain relief, but defecation again. Pain occurs again. The above clinical condition is called the anal fissure pain cycle. The pain can also be radiated to the perineum, buttocks, inner thighs or appendix.
2. Constipation This is the cause of anal fissure, and it is the consequence of anal fissure. After anal fissure, the patient is unwilling to defecate due to anal pain. Constipation is caused over a long period of time. The stool is more dry and hard. Constipation can make the anal fissure worse and form a vicious circle. Make the anal fissure difficult to heal.
3. Bloody stools often see a small amount of fresh blood on the surface of the stool or on the toilet paper, or drop blood, and large bleeding is rare.
4. Others such as anal itching, secretions, diarrhea, etc., are caused by the secretion of anal fissure ulcer or concurrent anal cryptitis, anal papillitis and other secretions, causing anal itching (Table 1).
5. Signs Foreign reports have reported 355 cases of anal fissure with the following different signs: 78% of anal fistula, 68% of sentinel fistula, 25% of hypertrophy nipple, 6% of anal fistula, 4% of sphincter abscess, 38%, anal canal stenosis 2% .
Examine
Anal fissure examination
In addition to the anus examination, there is usually no special examination, but if the cause is unknown or combined with other diseases, the appropriate inspection plan should be selected according to the specific situation.
1. Digital rectal examination and endoscopy for rectal examination and anal examination of the anal fissure that is difficult to diagnose. The operation should be gentle, so as not to cause severe pain to the patient.
2. Histopathological examination For chronic ulcers located in the lateral position, it is necessary to consider whether there are rare lesions such as tuberculosis, cancer, Crohn's disease and ulcerative colitis, and biopsy can be used for differential diagnosis.
Diagnosis
Anal fissure diagnosis
diagnosis
Ask about the history of fecal pain, with a typical pain interval and pain cycle, which is not difficult to diagnose. Local examination revealed a "triple sign" of the anal fissure in the medial part of the anal canal, and the diagnosis was clear. However, in the early stage of anal fissure, it is necessary to identify the anal fissure when it is diagnosed with anal canal skin. It is generally not suitable for digital rectal examination and anal microscopy to avoid severe pain. For chronic ulcers in the lateral position, it is necessary to consider whether there are rare lesions such as tuberculosis, cancer, Crohn's disease and ulcerative colitis. If necessary, biopsy should be performed.
Differential diagnosis
It must be differentiated from tuberculous ulcers, syphilis ulcers, soft chancre and epithelial cancer. Ulcerative colitis and granulomatous colitis are easily identified.
1. Anal skin abrasions Anal fissures need to be differentiated from anal skin abrasions (Table 2).
2. Intestinal inflammatory diseases Some intestinal inflammatory diseases may be accompanied by ulcers around the anus, which should be identified during diagnosis.
1 anal tuberculosis ulcer;
2 Crohn's disease anal canal ulcer;
3 syphilis ulcers;
4 ulcerative colitis complicated by anal fissure.
