Horst Mlitz

Therapy for Chronic Anal Fissure

Amazingly enough, the healing rates after treatment for chronic anal fissure stated in randomized controlled trials are extremely divergent. There are many reasons for that.

Sekundäre Analfissur infolge Leishmaniose

ZusammenfassungBei dem hier vorgestellten Fall aus dem Jahr 1995 handelt es sich um einen 54-jährigen AIDS-Patienten, der wegen eines malignen Non-Hodgkin-Lymphoms wiederholt chemotherapiert worden war. Aufgrund einer chronischen Analfissur und einer Abszedierung am proximalen Fissurrand erfolgte zur besseren Drainage, wie vor der HAART-Ära üblich, lediglich eine Wundtoilette – in diesem Fall eine sparsame Resektion des distalen Wundrandes. Histologisch zeigte sich fibromuskuläres Stroma mit entzündlichem Schorf und Granulationsgewebe. Im späteren Krankheitsverlauf wurde mittels Beckenkammbiopsie eine Leishmaniose diagnostiziert. Als Folge einer Literaturrecherche über sekundäre Fissuren wurde nun eine histologische Nachuntersuchung des damaligen Resektats durchgeführt. Dabei konnte im Bereich des analen Wundrandes ebenfalls eine Leishmaniose nachgewiesen werden.AbstractIn 1995 a 54-year-old man suffering from AIDS and malignant non-Hodgkin’s lymphoma presented with a chronic anal fissure and an anorectal abscess. For therapy, the distal edge of the lesion was excised. Histology showed mainly fibromuscular stroma and granulation tissue. Three and a half months later, a bone marrow biopsy led to the diagnosis of leishmaniasis. By reevaluation of the anal specimen focal accumulations of macrophages containing Leishmania could be detected most probably representing a secondary anal fissure due to anal leishmaniasis.

Therapy for Acute Anal Fissure

The therapy for acute anal fissure comprises the following methods: (1) basic therapy, (2) self-bougienage, (3) local therapy, (4) manual anal dilatation, and (5) lateral internal sphincterotomy.

Signs and Symptoms

The main symptom of anal fissure is persisting pain caused by defecation. It can last for several hours and abates very slowly. It can be burning, stabbing, piercing, dull, or even exert pressure. It can radiate into neighboring areas and become manifest or even increase while sitting, walking, or coughing. Passing of gas, too, can trigger pain symptoms.

Problems of Defining Chronic Anal Fissure

The definition of chronic anal fissure is inconsistent. Some authors define it on the basis of its time of existence (longer than 6, 8, or 12 weeks), others on the basis of morphological criteria like the depth of the defect, the condition of the edges of the fissure, or the existence of secondary changes such as skin tag, hypertrophied anal papilla, cryptitis, or fistula. All these clinical manifestations can be chronic anal fissure components, separately or jointly.

Diagnostics and Differential Diagnostics

Patients’ history determines the suspected diagnosis: strong pain during and/or after defecation as well as a blood strip on the stool column and/or traces of blood on toilet paper.

Secondary Anal Fissures

Only few, mostly older publications on anorectal complications of Colitis ulcerosa (ulcerative colitis, UC) can be found in medical literature. This is not astonishing, because contrary to Crohn’s disease, ulcerative colitis affects only the mucous membrane, but on no account the deeper layer of the bowel wall. Therefore, an increased rate of anal fissures associated with or induced by ulcerative colitis is not to be expected. This condition corresponds to our clinical experience. Whereas in 1964 Lockhart-Mummery had described even 23% anal lesions, mostly painful fissures in patients with a documented ulcerative colitis, the corresponding figures of 1972 dropped to only 7%. This result would suggest an improvement in differential diagnosis.

Medical Position Statement on the Diagnosis and Therapy for Anal Fissure

On the basis of our experience, we favor the following algorithm for diagnosis and therapy for an anal fissure disorder.

Historical Aspects of Anal Fissure Pathology

In her doctoral thesis, Willemsen (1963) quotes Boyer (1818) who points out in his paper on anorectal diseases that fissure-in-ano was first mentioned in medical literature in 1689. Frey (1943) claims that Boyer’s paper dates from 1825 and confirms that not only Louis Lemonnier in his “Traite de la fistule de l’anus ou du fondement” (1689) but also Raphael B. Sabatier has mentioned anal fissures in his “De la Medecine operatoire” (1824). This ostensibly negligible condition (Czerny 1903) creates “such extreme pain in the patient like no other with such tiny spatial dimensions” (Peters 1920).

Chronic Anal Fissure

Chronic anal fissure presents as longitudinal, deep ulcer, sometimes coated with smear. Secondary changes can occur in their development, such as hypertrophied anal papillae close to the proximal edge of the fissure at the level of the pectinate line, also pathologically altered crypts (anal cryptitis) or sentinel tags (secondary skin tags) with or without incomplete or complete fistula. At this stage, the wound edges are scarred and bulging, occasionally callused or undermined. Sometimes, the transversely running, now and then fibrous tissue of the internal anal sphincter appears at the fissure floor. It is not the duration of the existence of the anal fissure that is pathognomonic for the chronic anal fissure, but the appearance of the alterations mentioned earlier. The difficulty of a morphologically related definition of the chronic anal fissure is dealt with in Chap. 4.