Name Amnaj

avi
d
F/
Name Muhammadj
avi
d
Assi
gnment Adul
theal
thnur
sing
Topi
cname Analf
issur
e
Submi
tt
edt
o si
rawalsher
⁸
Def
ini
ti
on:
Ananal f
issur
eisasmal lteari
nthethin,moistt
issue
(mucosa)thatli
nestheanus.Ananal fi
ssur
emayoccur
wheny oupasshardorlargestoolsduri
ngabowel
mov ement.Analfi
ssur
esty pi
cal
lycausepainandbl eedi
ng
wit
hbowel movements.Youalsomayexper i
encespasms
i
nt heri
ngofmuscl eattheendofy ouranus(anal
sphinct
er).
Analfi
ssur
esarev erycommoni nyounginfantsbutcan
aff
ectpeopl
eofanyage.Ananal fi
ssureusuall
yhealson
i
tsownwi t
hinfourtosixweeks.Ifi
tdoesn't,
medical
tr
eatmentorsurgeryusual
l
ycanr eli
evediscomfort
.

Pat
hophysiol
ogyandEt i
ology:
Theexacteti
ologyofanalfi
ssur
esi
sunknown,
butt
he
i
ni ti
atingf act ori sthoughtt obet r
aumaf rom t hepassage
ofapar t
icular l
yhar dorpai nf
ul bowel mov ement .Low-
fiberdi ets( eg, thosel ackingi nr awf ruitsandv eget abl
es)
ar eassoci at edwi ththedev elopmentofanal fissures.No
occupat ionsar eassoci atedwi thahi gherr iskf orthe
dev elopmentofanal f i
ssures.Pr ioranal sur ger yi
sa
pr edisposi ngf act orbecausescar ringf r
om t hesur gery
maycauseei therst enosisort etheringoft heanal canal ,
whi chmakesi tmor esuscept ibl
et ot raumaf r
om har d
stool .
Initi
al mi nort ear sint heanal mucosaduet oahar dbowel
mov ementpr obabl yoccurof ten.I nmostpeopl e,t
hese
heal rapi dl
ywi thoutl ong-ter m sequel e.Inpat ientswi th
under l
yingabnor mal i
tiesoft hei nternal sphi nct er,
howev er,
thesei njur i
espr ogr esst oacut eandchr oni canal f
issures.
St udiesoft hei nternal anal sphinct erandofanal canal
phy siologyhav ebeenper formedwi t
hv ar i
edr esul ts,butat
l
eastoneabnor mal i
tyislikelypr esenti nt hei nt er
nal anal
sphi ncterofmanyanal fi
ssur epat i
ent .
Phy sicalExami nati
on
Initi
all
y,thef i
ssureisjustat earint heanalmucosaandi s
def i
nedasanacut eanal f
issure.Ifthef i
ssurepersist
s
overt ime, i
tprogressestoachr onicf i
ssurethatcanbe
distinguishedbyi t
sclassicf eatures.Thef i
bersofthe
i
nt ernalanal sphi
ncterarev isi
bleint hebaseoft he
chr onicfissure,
andof ten,anenl argedanal ski
nt agis
presentdi
stal
tothef
issur
eandhypert
rophi
edanal
papil
laear
epresenti
ntheanal
canalproxi
malt
othe
fi
ssure.

SYMPTOMS

Si
gnsandsy
mpt
omsofananal
fissur
eincl
ude:
 Pain,somet i
messev ere,duri
ngbowel mov ement
s
 Painafterbowel mov ementsthatcanlastupto
severalhours
 Bri
ghtr edbloodont hestoolortoi
letpaperaft
era
bowel mov ement
 It
chingori r
ri
tat
ionaroundt heanus
 Av i
sibl
ecr acki
nt heskinaroundtheanus
 Asmal l l
umporski ntagont heskinnearthe
 anal
fi
ssur
e.
Whent
oseeadoct
or

Seeyourdoctori
fyouhavepai
nduri
ngbowelmovement
s
ornot
icebloodonstool
sortoi
l
etpaperaf
terabowel
movement.
CAUSES

Commoncausesofanal
fissur
eincl
ude:
 Passinglargeorhardstools
 Constipati
onandst r
aini
ngdur i
ngbowel mov ements
 ChronicDiarr
hea
 I
nfl
ammat ionoftheanorectalar
ea,causedbyCr ohn'
s
di
seaseoranot herinfl
ammat oryboweldisease
 Chil
dbirth
Lesscommoncausesofanal
fissur
esi
ncl
ude:
 Analcancer
 HIV
 Tuberculosi
s
 Syphil
is
 Herpes
RI
SKFACTORS

Factor
st hatmayincr
easey
ourr
iskofdev
elopi
ngananal
fi
ssureinclude:
 Inf
ancy
.Manyi nf
ant
sexper
ienceananal
fissur
e
duri
ngthei
rfi
rsty
earofl
i
fe;
expertsar
en'
tsurewhy
.
  Aging.Olderadul tsmaydev elopananal fissurepart
ly
duet oslowedci rculation,r
esulti
ngindecr eased
bloodf l
owt other ectal ar
ea.
 Const i
pation.Straini
ngdur ingbowel mov ement sand
passinghar dstoolsi ncreasether i
skoftear i
ng.
 Childbir
th.Anal f
issur esaremor ecommoni nwomen
aftertheygivebirth.
 Crohn'sdisease.Thi si nfl
ammat orybowel di
sease
causeschr onicinflammat i
onoft heint
estinaltr
act,
whi chmaymaket hel i
ningoft heanalcanal more
vulnerabl
et otearing.
COMPLI
CATI
ONS

Compl
i
cat
ionsofanal
fissur
ecani
ncl
ude:
 Failuret oheal.Ananal f
issurethatf ai
l
st oheal wit
hin
sixweeksi sconsi deredchr onicandmayneedf urt
her
tr
eat ment .
 Recur rence.Oncey ou'
v eexperiencedananal fi
ssure,
youar epr onetohav i
nganot herone.
 At eart hatextendst osur r
oundi ngmuscl es.Ananal
fi
ssur emayext endi ntot heringofmuscl et hatholds
youranuscl osed( internalanalsphi nct
er),makingit
mor edi ffi
cultf
ory ouranal f
issuret oheal.An
unheal edf i
ssurecant ri
ggeracy cleofdiscomf ortthat
mayr equi remedi cat i
onsorsur ger ytoreducet hepain
andt or epairorremov et hefi
ssur e.
PREPARI
NGFORYOURAPPOI
NTMENT

I
fyouhav
eananal
fissur
e,y
oumayber
efer
redt
oadoct
or
whospeci
ali
zesi
ndigesti
vedi
seases(
gast
roent
erol
ogi
st)
oracol
onandrect
alsurgeon.
Here'
ssomeinfor
mati
ontohelpyougetreadyf
oryour
appoi
ntment
,andwhattoexpectf
rom y
ourdoctor
.
Whaty
oucando

 Wr
it
edownanysymptomsy ou'
reexperi
enci
ng.
 Wr
it
edownquest
ionstoaskyourdoctor.
Quest
ionst
oasky
ourdoct
or:

Somebasi
cquest
ionst
oasky
ourdoct
ori
ncl
ude:
 Whati
slikel
ycausingmysy mpt oms?
 Ar
ethereanyotherpossibl
ecausesf ormysympt oms?
 DoIneedanytests?
 I
smycondi t
ionli
kelytemporary(acut
e)orchroni
c?
 Whattr
eatmentsdoy ourecommend?
 Ar
ethereanydietar
ysuggestionsIshouldfol
l
ow?
Don'thesi
tat
etoaskot
herquest
ionsdur
ingy
our
appointment
.
Whatt
oexpectf
rom y
ourdoct
or

Yourdoct
ormayask:
 Whendidy oubegi nexper
iencingsymptoms?
 Haveyoursy mptomsbeencont i
nuousoroccasional
?
 Howsev er
ear ey oursymptoms?
 Wheredoy ouf eelyoursy
mpt omst hemost?
 What,i
fany t
hing,seemstoi mproveyoursy
mpt oms?
  What,i
fanyt
hing,seemstoworsenyoursymptoms?
 Doyouhaveanyot hermedi
calcondi
ti
ons,such
asCrohn'
sdisease?
 Doyouhavepr obl
emswithConsti
pati
on?
Whaty
oucandoi
nthemeant
ime

Whileyou'rewaiti
ngtoseeyourdoct or
,takestepstoavoi
d
Consti
pation,suchasdrinki
ngplentyofwat er,
addi
ngfibr
e
toyourdietandexercisi
ngregul
arly.Al
so, avoi
dstr
aini
ng
dur
ingbowel mov ements.Theex t
rapressuremay
l
engthent hefi
ssureorcreat
eanewone.
TESTSANDDI
AGNOSI
S

Yourdoctorwi
llli
kelyaskaboutyourmedicalhi
storyand
perf
orm aphysicalexam,incl
udi
nginspecti
onoftheanal
regi
on.Oftent
het earisvi
sibl
e.Usuall
ythi
sexam isall
that
'sneededtodiagnoseananal fi
ssure.
Yourdoctorwill
pr obabl
yrefr
ainfrom per
formingadi git
al
rect
alexam, whichinvol
vesinsert
ingaglovedfingerinto
youranalcanal,
becausei ti
slikel
ytobetoopai nful
.Ifanal
fi
ssureissuspectedbutcan'tbeidenti
fi
ed,yourdoctor
mayuseashor t
, l
i
ghtedtube(anoscope)toinspectyour
analcanal
.
Thef i
ssure'
slocati
onof f
erscluesaboutitscause.A
fi
ssurethatoccursont hesideoftheanal opening,
rat
her
thanthebackorf ront
,ismor eli
kel
ytobeasi gnof
anotherdisor
der,suchasCr ohn'sdi
sease.Ifanunderl
ying
condit
ionissuspected,yourdoctormayr ecommend
furt
hertesti
ng:
  Flexiblesi
gmoi doscopy .At hin,fl
exi
blet ubewi t
ha
ti
nyv ideocamer aisinsertedi ntothebot tom por ti
on
ofy ourcolon.Thistestmaybedonei fyou'r eyounger
than50andhav enor i
skf actorsforintestinal
diseasesorCol oncancer .
 Colonoscopy .Af l
exibletubei sinsert
edi ntoy our
rectum toinspecttheent i
r ecolon.Thist estmaybe
donei fyouareoldert hanage50orhav er i
skf actor
s
forCol oncancer,si
gnsofot hercondi ti
ons, orot her
sympt omssuchasabdomi nal pai
norDi ar rhea.
TREATMENTSANDDRUGS

Anal f
issur
esoftenheal wit
hinafewweeksi fyout ake
stepst okeepy ourstoolsoft
,suchasincreasi
ngy our
i
nt akeoff i
breandFluids.Soaki
nginwar m waterfor10to
20mi nutesseveral
timesaday ,especi
all
yafterbowel
mov ements,canhelprelaxthesphinct
erandpr omot e
healing.
I
fyoursy
mptomsper
sist
,you'
l
lli
kel
yneedf
urt
her
t
reat
ment.
Nonsur
gicalt
reat
ment
s

Yourdoct
ormayr
ecommend:
 Exter
nallyappli
edni t
ro-gl
ycer
ine,tohelpincrease
bl
oodf l
owt othefissureandpromot ehealing,andto
hel
pr el
axtheanal sphinct
er.Nit
ro-gl
yceri
nei s
general
lyconsider
edt hemedical t
reat
mentofchoi ce
whenot herconser
v ati
vemeasur esfai
l.Si
deef fect
s
mayincludeheadache.
  Steroidcr eams, tohelprel
ievedi scomf
ort
.
 Botulintoxi ntypeA( Botox)injecti
on,t
oparalyzethe
anal sphinctermuscleandr elaxspasms.
 Bloodpr essur emedi cati
ons, whichcanhelprelaxthe
analsphi ncter.Thesemedi cat i
onsmaybet akenby
mout horappl i
edexternall
yandmaybeusedwhen
ni
tro-glycer i
neinnotef f
ecti
v eorcausessignif
icant
si
deef f
ect s.
Sur
ger
y:

Ifyouhaveachr onicanal f
issurethatisresistanttoother
treat
ment s,
orifyoursy mptomsar esevere,yourdoctor
mayr ecommendsur gery.Surgeryusuall
yi nvolvescut
ting
asmal lport
ionoft heanalsphinctermuscl etor educe
spasm andpai nandpr omot eheali
ng.Sur geryhasasmal l
riskofcausinginconti
nence.
Postoper ativeCare
Sphincter otomyisper formedei therinanout pat
ient
setti
ngorasanof ficeprocedur e,andpatientsreturn
homet hesameday .Typical
ly,
mi nimalpostoperati
vepai
n
i
sassoci atedwi t
hei t
hertheclosedort heopen
technique—usual lynomor ethant hefi
ssurecaused
preoper ativ
ely.Painfrom thefissur estar
tstoabat e
almosti mmedi at
ely.Theonl ypost operat
iverestri
cti
ons
arefrom t heanest heti
c,andmanypat i
entscanr etur
nto
normal act i
v i
ti
esthef oll
owingday .

Compl
icat
ions
Compl
i
cati
onsf r
om sur
ger
yforanal
fissur
eincl
udet
he
fol
l
owi
ng:
  I
nfect
ion
 Bl
eeding
 Fi
stul
adev el
opment
 I
ncontinence(
themostf
ear
edcompl
i
cat
ion)

Long-Term Moni t
oring
Prescri
bestoolsoftenersandf ibersupplementat
ionafter
thesurger
y,andr ecommendf ibersupplementati
on
i
ndefini
tel
ytopr eventfutureproblemswi thconst
ipati
on.
Foll
ow-upcareusual lyconsist
sofasi ngl
epostoperat
ive
visi
ttoensurethatthewoundi shealingappropri
atel
yand
thatthefi
ssurehasr esolved.
Nur
singi
nter
vent
ion:
Acuteanalfi
ssure-Providersshoulduse
nonoperat
ivetr
eatments( e.
g.,si
tzbaths,psy
lli
um
fi
ber,andbulki
ngagents)ast hefi
rststepintherapy
(st
rongrecommendation, moderate-
quali
tyevidence)

Chr oni
canalf i
ssure-Providersshouldtr
eatchr
oni
c
anal fi
ssurewithtopical
pharmacol ogi
cagents(
eg,
calcium channelblocker
sorni t
rates)(
str
ong
recommendat i
on,moder at
e-quali
tyevi
dence)

Chr onicanalfissure-Pr ovider

sshoul dreferpat
ients
whodonotr espondt oconser vati
veorphar macologi
c
treatmentf orlocali
njectionsofbot ul
i
num t oxi
n
(strongrecommendat ion, l
ow-quali
tyev i
dence)or
i
nt ernalanalsphincterot
omy( str
ongr ecommendat i
on,
 hi
gh-
qual
i
tyev
idence

LI
FESTYLEANDHOMEREMEDI
ES

Youmaybeabl etopreventananalfi
ssur
ebytaki
ng
measurestoprev
entConst i
pat
ion.Eathi
gh-
fi
brefoods,
dri
nkFlui
dsandexerciseregul
arl
ytokeepfr
om havingt
o
st
raindur
ingbowelmov ements.
Addf i
bertoy ourdiet.Eatingabout25t o30gr amsoff iber
adaycanhel pkeepst oolssoftandi mprovefi
ssure
heal
ing.Fiber
-richfoodsi ncl
udef r
uits,
vegetables,nut
s
andwhol egrains.Youal socant akeaf i
bersupplement.
Addingfi
bermaycausegasandbl oati
ng,soincreaseyour
i
ntakegradually.
Dr
inkadequat
efl
uids.Fl
uidshel
ppr
eventconst
ipat
ion.
Av oi
dstraini
ngduri
ngbowelmovement
s.St
rai
ning
createspressur
e,whi
chcanopenaheal
i
ngtearorcausea
newt ear
.