Fissure in-ano- lower gi hemorrhage

Fissure in-ano- lower gi hemorrhage

• 1.
  LOWER GI HEMORRHAGE FISSURE-IN- ANO Dr.B.SELVARAJ MS;Mch;FICS: PROFESSOROF SURGERY MELAKA MANIPAL MEDICAL COLLEGE MELAKA 75150 MALAYSIA
• 2.
  FISSURE-IN-ANO Causes of LowerGI Hemorrhage Etiopathogenesis Types of Fissre-In-Ano Clinical features Treatment Mindmap Diagnostic algorithm Management Algorithm
• 3.
  Causes for LowerGI Hemorrhage Diverticular disease Angiodysplasia- AV Malformation Colorectal carcinoma Hemorrhoids Fissure-in-ano Ischemic colitis Inflammatory bowel disease Meckel’s diverticulum Upper GI hemorrhage
• 4.
  CLASSICAL CLINICAL VIGNETTE A 23year old lady describes excruciating pain with defecation and blood streaks on the outside of the hard stools. Because of the pain she avoids having bowel movements and when she finally does, the stools are hard and even more painful. Physical examination can not be done, as she refuses to allow anyone to even “spread her perianal area” to look at the anus for fear of precipitating the pain. Diagnosis: Fissure-in-ano EUA should be done to R/O other pathologies like Anal Carcinoma, Crohn’s disease, Tuberculosis, HIV and Leukemia
• 5.
  ETIOPATHOGENESIS  An analfissure is an ulcer in the lower portion of the anal canal Most tears of the anal canal are due to the passage of large, hard stool or explosive diarrhea, trauma to the anus, or a tear during vaginal delivery. Patients have increased resting anal pressure caused by the increased tone of the internal sphincter muscle. This results in ischemia and ulceration to the overlying anal skin. In men, almost all fissures are located in the posterior midline, whereas in women, 10% are in the anterior midline.
• 6.
  Types of Fissure-in-Ano Acute Fissure-in-Ano: Symptoms within one month Chronic Fissure-in-Ano: Symptoms 2 to 3 months duration  The primary fissure occurs without association with other local or systemic diseases The secondary fissure occurs in association with Crohn’s disease, leukemia or aplastic anemia.
• 7.
  Clinical Features Bleeding perrectum: Bleeding is painful associated with defecation. It is bright red blood and blood usally streaks on the hard fecal matter Painful defecation: Anal pain during and after defecation is the most prominent symptom.The pain is described as burning, throbbing, or dull aching. Physical examination confirms the diagnosis. Chronic fissures have a triad of a fissure, sentinel skin tag, and hypertrophied anal papilla  In acute Fissure-in-Ano you shouldn’t do DRE or Proctoscopy for fear of aggravating the pain.
• 8.
  TREATMENT Nonoperative for allAcute and some chronic Fissure-in-Ano a. Sitz bath—The patient is asked to sit in warm water with the anal region and buttocks dipped in water for about 20 minutes,2 to 3 times a day. This reduces pain, edema and promotes healing. b. Antibiotics, laxatives (stool softener) and antiinflammatory drugs are beneficial. c. Regulation of bowel habit with a high fiber diet. d. Local application of nitroglycerin or calcium channel blockers like diltiazam lowers the resting anal sphincter tone. e. Injection of Botulinium toxin lowers the resting internal sphincter tone.
• 9.
  TREATMENT Operative Treatment:  Analfissures usually heals in six weeks. Surgery is not usually required unless the conservative therapy fails.  Lateral internal Sphincterotomy is the surgical procedure of choice if the anal sphincter tone is normal. This can be done as open or blind subcutaneous lateral internal Sphincterotomy. If anal sphincter tone is low- do endoanal v-y skin flap Fissures or ulcers in Crohn’s disease are larger and deeper than primary anal fissures. The surrounding skin is macerated and edematous. Treatment consists of proper anal hygiene and treatment of the underlying inflammatory disease.
• 10.
  TREATMENT Notaras Closed blindsubcutaneous lateral internal sphincterotomy Open subcutaneous lateral internal sphincterotomy
• 11.
  MINDMAP
• 12.
  Diagnostic Algorithm
• 13.
  Treatment Algorithm
• 14.
  THANK YOU LIKE SHARE SUBSCRIBE