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06-04-2008, 09:07 AM
mDefinition: Loss of continuity of the anoderm
mCauses: 1- Overstreching of the anoderm due to:
a- passage of hard faecal mass.
b- Excessive straining in labour ant. fissure
2- Trauma of foreign body, endoscopy or operation.
3- Chronic specific lesions e.g. Crohn's disease.
mPathology:
Site: Commonly posterior > anterior 90 : 10
In females ant. fissure incidence increases but post. fissure is still common.
* Why it is common posteriorly?
1- Due to rectal curvature: maximum stretch of the anal verge is posteriorly.
2- Fixation of the anoderm to the muscle layer posteriorly not anteriorly.
* Why ant. fissure is more in females?
1- Overstretch during labour.
2- Repeated perineal tears weaken ant. wall.
m Types: 1) Acute fissure accompanied by spasm
2) Ch. fissure accompanied by:


a-Sentinel pile: oedematous skin tag at the anal verge
b-Perminant spasm: due to fibrosis at the base.
c-Hypertrophied anal papilla at its apex.
d- Infection abscess or fistula.
m Clinical Picture:
1) Acute fissure: Severe pain, reflex retention of urine or dysuria and constipation. PR. is impossible.
2) Chronic fissure:
Recurrent attacks of pain. Bleeding & discharge / rectum.
Sentinel pile on examination.
m Treatment:
(A) Acute type:
The main aim is to relax the spincter spasm, to increase blood supply which gives better healing, and to relax the sphinctere to prevent faecal trauma.
1- Conservative treatment :
a- Ointment which is
Local anaesthetic. Decongestant. Disinfectant.
b- Laxative loose stool
2- Dilatation under anaesthesia temporary paralysis of the sphincter.
(B) Chronic type:
* Fissurectomy and sphincterotomy =
- Excision of the fissure with sentinel pile and cutting of lower fibers of int. sphincter at the base of the fissure.
* Lateral sphincterotomy alone may give cure.
SOURCE: DR. AYMAN SALEM'S BOOK
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