Anal fissure or guda parikartika- ANote

Longitudinal tear in the anal canal.

1. 1

Anal Fissure: Longitudinal tear in the anal canal.
Site: Posterior midline (90%) and Anterior midline in 10% case especially in females.
Etiology & Predisposing factors of Anal Fissure:
▪ Age: Young adult & middle-aged man.
▪ Gender: Male > Female.
▪ Posterior midline is the commonest site because- Maximum stretching on this site - Less
tissue here -Minimal tissue perfusion.
Etiology of Anal Fissure -
▪ Main cause-Trauma–Strained evacuation of Hard stool
▪ Less commonly - Repeated passage of stool (diarrhea)
▪ Anterior anal fissure in 10% cases – Mostly in Women that occurs following vaginal
delivery
Predisposing Factors: FISSURE
▪ Faces – Hard
▪ Ischemia
▪ Surgical procedure- Hemorrhoidectomy.
▪ Sphincter hypertonia
▪ Underlying disease – Crohn’s diseases, TB, L.V, Syphilis etc.
▪ Repeated Childbirth
▪ Enthusiastic usage of ointments and abuse of laxatives.
C/F of Anal Fissure:
▪ Severe anal pain during the defecation
▪ Blood streak outside the stool
▪ Bleeding P/R- Bright red i.e, fresh bleeding.
▪ Mucous Discharge
▪ Constipation
▪ Itching
Chronic Anal Fissure: Findings-
▪ Hypertrophied Anal Papilla- Proximally
▪ Sentinel tag- Distally***
▪ Thickened edge
▪ Exposed internal sphincter i.e. Ulcer overlying the fibers of internal sphincter.

Differential diagnosis –Especially if ectopic site i.e., other than Posterior –midline: Crohn’s
Diseases, Kaposi’s Sarcoma, Tuberculosis, B-Cell Lymphoma, Lymphogranuloma Venereum,
CMV Syphilis, Chlamydia, HIV, Chancroid, HSV etc.
Confirmation of Diagnosis-
▪ Adequate clinical examination.
▪ Proctoscopy
▪ Sigmoidoscopy

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▪ Take Biopsy
▪ Do Culture
Treatment: Conservative & Surgical
▪ Conservative treatment helpful in most of cases.
▪ Main objective to treat Constipation.
▪ -Add the fiber to the diet
▪ -Encourage water intake
▪ -Laxative to make the stool soft
▪ Application of local anesthetic-Lignocaine jelly
▪ Antibiotics- Ofloxacin + Ornidazole if there is infection.
Conservative:
▪ Hot Sitz Bath.
▪ Drugs that release the Nitric oxide donor- Glyceryl Trinitrate ( GTN) 0.2 % & Diltiazem
2%. GTN 0.2% - QID at Anal Margin – [ S/E- Headache and Recurrence]
▪ Diltiazem 2%- BD at anal margin
[Mechanism of action- Produces NO – Relaxation of the internal Sphincter- reduces the
spasm, pain & increase the vascular perfusion to promotes healing.]
▪ Botulinum toxin injection.
Site of Injection- Internal Sphincter
[Mechanism of action- Inhibits presynaptic release of Acetylcholine from cholinergic nerve
endings- Paresis of Striated muscle and releases the spasm.]
(#Other use- Achalasia cardia, Sphincter of Oddi dysfunction, Frey Syndrome).

Operative procedure for Fissure in Ano-
▪ Anal Dilatation
▪ Lateral Anal Sphincterotomy of Notaras
▪ Anal advancement Flap
Anal Dilatation:
▪ Lord’s Anal Dilatation
▪ Position- Lithotomy, Under G/A
▪ Manual 4 to 8 finger sphincter dilatation
▪ Useful in Young men with very high sphincter tone
▪ Risk of Incontinence.
Posterior division of the exposed fibers of the internal sphincter in the base of the fissure
• Indication – if fissure is associated with INTERSPHINCTERIC FISTULA
• Disadvantage- Prolonged healing – Passive anal leakage because of resulting, Keyhole gutter
deformity’.
Lateral Anal Sphincterotomy:
▪ Position- Lithotomy
▪ Anesthesia- Regional or G.A

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▪ Palpate the distal internal sphincter with the help of bivalved speculum at the
intersphincteric groove. → Give a small longitudinal incision in right or left lateral
position→ Cut the Mucosa Get the sub- mucosal & Intersphincteric planes. Allow the
Exposure of Internal sphincter →Cut the Internal sphincter up to the apex of the fissure
→Closed the wound with the absorbable suture.
Complications of LAS:
▪ Hemorrhage
▪ Hematoma
▪ Bruising
▪ Perianal Abscess
▪ Fistula
▪ Incontinence.
Anal Advancement Flap:
▪ Very useful in women and those with Normal or Low Resting Anal Pressures (persistent,
chronic, non-healing fissure)
▪ Excised the edge as well as base of the fissure.
▪ Inverted house shaped flap of Perianal skin is mobilized to cover the fissure.
▪ Post-op instruction- Stool softeners, Bulking agent & Topical sphincter relaxants.

Basic points for Examination of Anal Canal:
1. Relaxing your Patient.
2. Ask for Consent.
3. Make Private environment
4. Good Light Exposure.
5. Position – Left Lateral Position/ Sim's Position- most commonly used.
6. Other positions- Lithotomy, knee- elbow position.
7. P/R Examination: Inspection -Skin Lesion- Psoriasis, Lichen planus. Warts, eczema,
Candidiasis Herpes simplex. etc.
8. Whether anus is closed or patulous. Position of the anus/perineum. Evidence of piles/
sentinel tag (Anal fissure)
For P/R (per rectal examination): Gloves, jelly etc. kept ready
Sling of puborectalis- Posteriorly at the apex, Posterior surface of the prostate gland with
median sulcus (Male) & Uterine cervix (in female).
Anteriorly- Intrarectal, Intra anal or extraluminal mass. Sphincter length, Resting tone, Voluntary
squeeze.
Examining finger – look for Mucus, Blood, Pus, Stool Color etc.

Proctoscopy-
▪ Position: Left lateral position
▪ Inspection of the distal rectum and anal canal

4. 4

▪ Injection in Hemorrhoids
▪ Banding of Piles mass
▪ Biopsy of mass
Sigmoidoscopy: Mainly used for Rectal examination but also recommended in Fissure &
Hemorrhoids, Colitis & Rectal Carcinoma etc. Rectal is frequently A/W Fissure & Hemorrhoids.

Ayurvedic management for Anal fissure-
In Ayurveda it is termed as Parikartika/ Guda Parikartika.
Management is
▪ Sitz bath (Avagaha sweda)- sit in warm decoction of Triphala and haldi/ Panchavalkala
kashaya , once daily for 15minutes.
▪ Local application / Pichu - Of jatyadi taila / jatyadi ghrita/ shatadhauta ghrita etc.
▪ If there is Arsha and Parikartika at a time then kashisadi oil is useful along with oral
medication.
▪ Oral medication –
Pain during defecation is the main complain. To get relived from this following
medication are useful.
If constipation is present then- Avipattikar churna, Panchashakar churna, triphala churna,
almaki churna, haitaki churna etc are usefull (any one). others medicines are -
Sukumara ghrita
Dusparshakadi kashaya
Abhayaristha
Triphala guggulu
Kaisor guggulu
Kalyanak guda
If there is bleeding -Bolabaddha rasa, Nagkeshar churna, ayapana churna, pushyanug
churna, yastimadhu ghrita etc are usefull.
Parikartika along with Aama is treated with – Chitrakadi voti, Baiswanor churna with
Vajra kshara etc. these medicines are used with precaution if there is bleeding in
parikartika.
Avoid -
▪ Veg dharana.
▪ Weight lifting.
▪ Spicy food.
▪ Fast food. etc.
▪ Take plenty of water and vegetables.