QuestionSBA
QuestionChoice
This is normally associated with crampy ano-rectal pain at night rather than rectal bleeding.
10017180
e
Proctalgia fugax
QuestionChoice
This would be rare in a young patient and would likely present with a longer history of symptoms and weight loss. In addition, there may possibly be a palpable mass on examination.
10017178
c
Rectal cancer
QuestionChoice
A short history of painful defecation with bright red blood passed is most likely to be an anal fissure rather than other more sinister pathology. Advice to increase dietary fibre and fluid intake as well as keeping the area clean and dry should be provided.
10017176
a
Anal fissure
QuestionChoice
Whilst this can present similarly to anal fissures, they are less likely to be associated with pain on defecation and there would likely masses that were palpable on rectal examination.
10017179
d
Haemorrhoids
QuestionChoice
Whilst this may present with rectal bleeding, the short history of symptoms, lack of increased frequency of stool passage and the lack of constitutional symptoms point away from inflammatory bowel disease.
10017177
b
Inflammatory bowel disease
QuestionComment
surely they wouldn't even tolerate a PR w a fissure??
42559
User
subscriber
Aaron
QuestionComment
Agreed ^^

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Hypertension Kinase
Concept
Chapter
# Summary

Anal fissures are commonly experienced by patients as severe anal pain or a tearing sensation while passing stools, persisting for hours afterward. Typical signs and symptoms include anal spasms and per rectum (PR) bleeding. Key risk factors are constipation and pregnancy. The initial management is typically conservative, including treatment of constipation and use of topical analgesics and vasodilators. For resistant cases, topical calcium channel blockers or oral medications can be used. Referral to a gastroenterologist is recommended for atypical cases or those suspected of Crohn's disease.

# Definition

Anal fissures are linear tears or cracks in the distal anal canal, often causing severe pain and bleeding during or after bowel movements.

# Epidemiology

Anal fissures are a common condition in the general population. However, they are more frequently encountered in certain groups such as those suffering from chronic constipation and pregnant women, particularly during the third trimester or post-delivery.

# Aetiology

Anal fissures occur due to various causes, most notably:

-   Constipation: Hard stools can cause tearing in the distal anal canal.
-   Pregnancy: Increased risk during the third trimester and post-delivery.

# Signs and Symptoms

Patients with anal fissures typically present with the following symptoms:

-   Severe anal pain or a tearing sensation during bowel movements, lasting for hours afterward.
-   Anal spasms reported by about 70% of patients.
-   Bright red PR bleeding typically noticed on the stool or the toilet paper.
-   Over 90% of fissures are in the posterior midline, visible on parting the buttocks.
-   In chronic cases, a sentinel pile (skin tag) may be visible.
-   In severe cases, digital rectal examination may not be possible due to pain.

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# Differential Diagnosis

The differential diagnosis for anal fissures includes other conditions causing anal pain or bleeding, such as:

-   Hemorrhoids: Painful, swollen veins in the lower portion of the rectum or anus. Signs include painless bleeding during bowel movements, itching or irritation in the anal region, discomfort, swelling around the anus, and a lump near the anus.
-   Anal abscess or fistula: Symptoms include anal pain, rectal discharge, bleeding, irritation, and fever.
-   Anal cancer: Symptoms can include anal bleeding, anal itching, a lump or mass at the anal opening, pain or feeling of fullness in the anal area.
-   Inflammatory bowel disease (Crohn's disease or ulcerative colitis): Symptoms include diarrhea, rectal bleeding, abdominal cramps and pain, an urgent need to move the bowels, and weight loss.

# Investigations

Investigation of anal fissures primarily involves a physical examination, including inspection of the anal area and potentially a digital rectal examination (if tolerable by the patient). Further investigations may be warranted in atypical cases or in those with potential signs of systemic disease like Crohn's disease.

# Management

The management of anal fissures involves both conservative and pharmacologic strategies:

-   Treatment of constipation with the use of laxatives and dietary fiber.
-   Use of topical analgesics, such as lidocaine cream or jelly.
-   Application of topical vasodilators like nifedipine or nitroglycerine.
-   Second-line treatments include topical calcium channel blockers (diltiazem), or oral nifedipine / diltiazem.
-   Patients with atypical anal fissures or symptoms/signs suggestive of Crohn's disease should be referred to a gastroenterologist.

# NICE Guidelines

[NICE CKS - anal fissures](https://cks.nice.org.uk/topics/anal-fissure/)

# References

[NHS - anal fissures](https://www.nhs.uk/conditions/anal-fissure/)
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A picture of an anal fissure.
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Anal Fissure
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General Surgery
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Anal fissures typically present with bright red blood and pain during defecation, often linked to constipation or straining.
A 28-year-old-male notices bright red blood in the toilet bowel after opening his bowels for the last 3 days. He experiences pain when passing stool. He denies any weight loss or abdominal pain. He usually opens his bowels once a day. There are no palpable masses on rectal examination.

What is the most likely diagnosis?
a