The cause of disease
1. Abnormal stool
Anal fissure is first caused by the impact or friction of external force. If the feces are too thick and hard, the anal adaptability is poor at this time, which will crack the anal canal. Studies have found that not only constipation but also diarrhea can cause anal fissure, which can account for 4% ~ 7% of the causes of anal fissure.
2. Spasm of internal sphincter
Abnormal emotions such as inflammatory stimulation of intestine, anal canal or anal sinus, acid stool stimulation, sphincter exposure, anger, tension, etc. can all cause high tension of internal anal sphincter, which can cause the resting pressure of anal canal to increase obviously. In this case, the anus is not stretched enough, and cracks will appear when dry feces pass through.
3. Anatomical defects
The external anal sphincter forms two triangular cracks in front of and behind the anal canal, which lacks sufficient support for the anal canal, but it can be cracked when feces impact. At the same time, the anal artery is distributed from both sides to the middle and crosses the anus. It leads to the formation of two weak distribution areas before and after anus, which leads to poor blood supply in this area. The anal canal and rectum extend at a 90-degree angle, and the pressure on the back wall of the anal canal is the greatest when defecating, so anal fissure is most likely to occur on the posterior median line.
clinical picture
The typical clinical manifestations of anal fissure are pain, bloody stool and constipation.
1. Pain
It is the main symptom of anal fissure, and the degree and duration of pain indicate the severity of anal fissure. A typical anal fissure pain cycle is: pain-relief-peak-relief-pain again. When defecating, feces stimulate nerve endings on the ulcer surface, causing severe burning sensation or knife pain after defecation, which can radiate to buttocks, perineum, sacrococcygeal region or inner thigh, which is called defecation pain. The pain is relieved in a few minutes after defecation, which is called the pain interval. After that, due to internal sphincter spasm, there will be severe pain that lasts for several minutes or hours. At this time, the patient will be restless and unbearable until the sphincter is tired, the muscles are relaxed and the pain is gradually relieved. When I defecated again, the pain reappeared.
2. bloody stool
It is mainly blood dripping during defecation or blood smeared on paper after defecation, and the blood color is bright red. The amount of bleeding is related to the depth and size of the fissure, but there is no bleeding like hemorrhoids, and there is little bleeding. Anal fissure stool bleeding will also recur periodically.
3. Constipation
Many patients with anal fissure have constipation themselves. Some patients suffer from anal pain after anal fissure and are afraid of defecation. Over time, the feces become more dry and hard, and constipation will aggravate anal fissure, thus forming a vicious circle.
Four inspections
Anal fissure examination is also very simple, and it can be completed in anorectal clinic without special equipment. But pay attention to look and touch, but don't use anoscope casually, so as not to cause greater pain and anal laceration to patients.
1. Look
(1) Seeing "sentinel hemorrhoid", patients with anal fissure usually grow redundant skin on the front and back sides of anal margin, which is clinically called "sentinel hemorrhoid" and is one of the important signs of anal fissure.
(2) Seeing that the fissure is located in the middle of the anus, you need to gently pull the anus to see it. See if the crack is fresh and how deep it is. Sometimes you can see that the fissure is white, which means that it is deep and has broken into the fascia tissue on the surface of the internal sphincter.
touch
Finger diagnosis of anal fissure must be light, slow and soft.
(1) Touch the tension finger cuff of anal canal, put more lubricating oil, and gently put it into anal canal to feel the tension of anal canal, so as to judge the severity of anal fissure. The tension of anal canal is too large, even if there is no crack, it should be treated.
(2) The severity of touch scar tissue and fistula scar tissue indicates the course and prognosis of anal fissure. Anal fissure complicated with subcutaneous fistula also needs finger diagnosis to judge.
(3) Patients with anal fissure should try not to use an anoscope when touching the anal nipple. You can check whether there is anal nipple hypertrophy with your fingers.
Five diagnoses
According to the medical history, typical clinical symptoms and findings during examination, it is not difficult to diagnose. If the edge of anal fissure is soft and tidy, the bottom is shallow without scar, the color is reddish, and it is easy to bleed, suggesting acute anal fissure. If there are scars around the fissure, the bottom is irregular in depth, grayish white, and it is not easy to bleed, and there is a "anal fissure triad", which means that it is chronic anal fissure.
Six therapies
Most patients with chronic anal fissure correct primary constipation or diarrhea, or take experimental treatment with local drugs in clinic. Patients with poor conservative treatment effect can consider anal fissure resection and/or lateral incision of internal sphincter. Acute or primary anal fissure can be cured by increasing fiber and water intake and warm water sitz bath.
1. Correct abnormal defecation
Constipation is one of the main symptoms of anal fissure and the main reason for its formation. We can soften the stool by adding dietary fiber food or supplementing vitamins with drugs to keep the stool smooth. For constipation, laxatives and probiotics can be added.
Clean the anus and take a bath.
Take a bath with 1:5000 potassium permanganate warm water after defecation or before going to bed, and keep it clean locally.
3. Local drug therapy
(1) Analgesic anesthetics (such as lidocaine gel) and non-steroidal anti-inflammatory drugs (such as diclofenac cream and ibuprofen cream) can relieve pain symptoms.
(2) hemorrhoid ointment and recombinant human epidermal growth factor for promoting wound healing.
(3) Nitroglycerin ointment was applied to anal fissure with 0.2% nitroglycerin ointment twice a day for 5-8 weeks. The medicine has the functions of inhibiting neurotransmitters, relaxing smooth muscle, dilating blood vessels, relaxing internal sphincter, reducing anal canal pressure and improving local blood circulation.
(3) Local injection of small dose of botulinum toxin can weaken the tension of internal sphincter. Injection of 0. 1ml diluted botulinum toxin into the external sphincter near anal fissure leads to chemical denervation and local muscle paralysis, thus reducing muscle tension.
Dilate anus
It is suitable for acute and chronic anal fissure without nipple hypertrophy and sentinel hemorrhoids. Expanding anus with fingers or instruments (bellmouth anoscope commonly used in anorectal department is enough) can relieve anal pain to some extent, but it will recur, and may be complicated with adverse reactions such as anal hematoma, bleeding and anal incontinence in a short time.
5. Surgical therapy
It is suitable for patients with chronic anal fissure who are ineffective in anal fissure triad or non-surgical treatment. Commonly used surgical methods include anal fissure resection and lateral internal sphincterotomy.
Seven defenses
It is important to keep a relaxed and happy attitude. Treating and preventing constipation is the most important way to prevent anal fissure recurrence. Pay attention to the cleanliness of the anus, and develop the hygienic habit of cleaning the anus in time after defecation. Anal sinusitis, anal papillitis, perianal eczema, perianal dermatosis and other perianal inflammatory diseases should be treated in time. This can effectively prevent the occurrence and recurrence of anal fissure.
8. Reference materials
Wang Yanmei. Clinical observation on 340 cases of chronic anal fissure treated by anal canal loosening and pathological tissue resection [J]. China Journal of Anorectal Diseases, 2002,22 (9):11.
Lv Houshan, Wang Shan. Colon and rectum surgery [M]. Fourth edition. Beijing: People's Health Publishing House, 2002, 188-20 1.