Anal fissure non surgical tt the lect.ppt

A short summary about the conservative treatment of anal fissure describing the various method used about this method . Describing the details of each method what is the drug used and how it works and its side effect

1. ANAL FISSURE
NON SURG TT
HAMED RASHAD
Professor of surgery Banha faculty of
medicine - Egypt

3. Squamocolumnar

Junction Rectum

¿Anal Columns

y: of Morgagni

ン Pectinate or
"^ Dentate Line

WA „Internal

Be

ン He) ㅣ ^ Sphincter Muscle
/ =

A ~
7 | 1 (eae LES Anal Crypt
} i SE Anal Gland
NET, \ ー

Surgical Anal Canal
Anatomical
Anal Canal

- \ \
Sweat Glands and Anal Verge Anoderm \External
Hairs in Perianal Skin Sphincter Muscle

4. Formation of anal
sphincters

トド Rectum

aan = ご Longitudinal
muscle of rectum
Internal sphincter
8 Longitudinal
> External _— layer of anal canal
— sphincter 一 [EL Genitourinary
muscle ~ viscus

À ici
muscle

5. _ Chronic anal fissure
» Duration - 2 months or more.

Deep benign indurated ulcer with undermined edges

Internal sphincter fibres may be seen

Inferiorly - oedematous skin tag

Superiorly - hypertrophied anal papilla

Relative anal stenosis secondary to spasm or fibrosis of
the internal sphincter.

6. CONS]
\STIPATION

7. Secondary to
Crohn's disease

Hidradinitis suppurativa
Syphilis

Anal Tuberculosis

8. CIINICA CEATIIRE
CLI IN CAL U EA! U II
Pain - sharp, tearing ,agonizing
lasting an hour or more

provoked by defecation
associated spasm

Streaks of blood - 80% cases (bright red)
Slight mucoid discharge - chronic fissure
Peri-anal irritation

remission for days or weeks may occur

Patients tend to become constipated rather than
suffer the agony of defaecation.

9. Local examination

Inspecet the anal verge by gentle seperation of the
gluteal cleft

Longitudinal split

_ fissure Chronic fissure

May not allow to touch Be 。
Indurated margins

Superficial ulcer Undermined edge

Mild induration Internal sph. May be seen

Internal end - enlarged papilla
External end - oedematous skin tag

10. ar FAT LS | DT
Icdiidscri HUG
L

Safe

First step in therapy.

Few side effects - Preserve continence

Level of evidence: Class II;

Grade of recommendation: B.

Surgery - for failures of pharmacological treatment
or fissures that recur frequently after cessation of
local treatment.

11. 11

12. テー
==)
LA
zZ
D
E

an 4
=

mn
Mm

IT

N

Most of the aute fissures

a Heal spontaneousl
40% of chronic fissures P y

aided by conservative measures

Constipation
bulk laxatives
dietary fibre
plenty of liquids

13. Regular ces ads - He
Local anaesthetic cream - 2% or 5% lignocaine — 4 weeks
Topical steroids - 1% hydrocortisone - short course
Chemical sphincterotomy

Nitric oxide donars

Botulinum toxin A

Newer agents - Ca chan. Blockers

Smooth muscle relaxants

a-adrenoreceptor antagonists(16), B-adrenoreceptor agonists(17) and
parasympatho-mimetics such as bethanecol under trails.

14. Nit | ri IC OX ide = done ars
0.2% 0.5g 8weeks
once a day
if pain persisting
twice a day Héacache
if no headache
thrice a day
GTN releases Nitric oxide
NO is major neuro-inhibitory transmitter of [AS
27 % recurrent in RE (RCT)

1per cent bide dimitrate Ointment applied five to
six times a day results in healing of 80 per cent of
chronic anal fissures 14

15. Dr hit NASA
RN | ım rn M
Botulinum toxineA

Potent neurotoxin

inds to pre-synaptic cholinergic nerve terminals
at the

neuromuscular junction.

When injected into the -
paralysis results that may last for three to four months.
Heals up to 82% of chronic anal fissure with a 6%
recurrence rate at six months.
Incontinence occurs in 7%
wii perianal thrombosis;

“and = minimisethe
widespread use of babe toxin RE nite evidence
that support its effectiveness. a

16. Nifidipine, Diltiagem
blocks slow L-type calcium channels in smooth
muscle causing relaxation.
Chronic fissure healing 60% - 75% in 8weeks
Alternative to GTN with same efficacy
High patient compliance - no adverse effects

17. Indicated
Not heal with conservative measures - recurrent
when severe pain precludes

Manual anal dilatation
Sphincterotomy
Anal advancement flaps
? Biopsy

18. 用 O oo ae
an = sans Ailatatinn
al 1 Ｌ al died! dilatat on

Pain relief , variable healing rates
Uncontrolled - may impair anal continence permanently.
Recurrence rates - 2 to 57 percent,

Anal USG has demonstrated - disruption and
fragmentation of the internal sphincter.

More controlled dilatation with an anal speculum ora
balloon are proposed to be safer but this claim has not
been substantiated.

No longer recommended.

19. mbr jas a te Ah に ーー
nternal SPNINCTEFOTOMY
This is the surgical division of the of the

dividing the sphincter in the ‘3 o'clock’ or 'g o'clock’
position.
This is the surgical procedure of choice for

quick, simple, provides immediate relief of pain in
uncomplicated cases of anal fissure

Surgery

20. Open internal sphincterotomy

Incislon Fr. /
(a) Parks anal retractor openod ーー 4 6
put internal sphincter on stratch.

Traction applied to retractor make

internal sphincter easily visible, ] (b) Internal sphincter is dissected

and crushed (up to the ‘apex’ of
the fissure) using artery forceps.

> (c) Crushed sphincter is divided
— = デー with scissors

21. EUA & rigid sigmoidoscopy

fissure should first be pinched between finger and
thumb in order to determine whether there is any
pea-like induration in association with it. If there
is, then it is likely there is an

- dorsal sphincterotomy

Parks’ anal retractor puts the internal sphincter on
stretch

small incision in the skin overlying the
intersphincteric groove and to pass a pair of

scissors submucosally as far as the dentate line and

then intersphincterically for the same distance.

21

22. internal sphincter is now isolated. Crushing it
momentarily with artery forceps before cutting it
will avoid sometimes rather troublesome bleeding.

retractor can now be rotated to tamponade the
operation site

sentinel or fibroepithelial polyp is removed
rates in excess of can be expected
within E

Women - vaginal delivary - 30% - occult sphincter
injury - ill adviced

22

23. A nal adva a

Ce] m 1e À NT

surgery or trauma to the anal sphincter
recurrent anal fissures

anal ultrasound to check that the internal sphincter
has indeed been divided

advancement flap of perianal skin to the fissure in an
attempt of primary healing
V-Y (rhamboid flap) plasty.

23

24. (a) Non-healing fissure is excised
and a rhomboid island flap is
constructed

Fat and
vascular
pedicle

bj The fully mobilized flap with
Its subcutaneous fat and
vascular pedicle Is advanced
to fill the excised defect.

$

(ci Island flaps is sutured and donor