QuestionSBA
QuestionChoice
Proctalgia fugax leads to intermittent severe pain localised to the rectum. It will usually completely resolve within seconds to minutes. The cause is unknown. Proctalgia fugax would not lead to spots of bright red blood on wiping
32971
d
Proctalgia fugax
QuestionChoice
Internal haemorrhoids would be a differential in this case. The bright red blood on wiping and the constipation risk factor could suggest internal haemorrhoids. However, internal haemorrhoids are not severely painful, which makes anal fissure the more likely diagnosis
32969
b
Internal haemorrhoids
QuestionChoice
Ulcerative colitis would be a differential for this patient due to the bright red blood on wiping. However, the pain profile is usually different. For example, abdominal pain is much more common than pain on defecation, which is a classic feature of anal fissures
32970
c
Ulcerative colitis
QuestionChoice
Anal fissures are usually very painful when defecating and are classically described as like passing glass. This pain may persist for hours afterwards. Constipation is a risk factor for anal fissures. On examination, they are linear and have clear edges. Most will heal after a few weeks of conservative management; however, some will require surgical intervention
32968
a
Anal fissure
QuestionChoice
Crohn's disease would be a differential for this patient. However, the pain profile is usually different. Abdominal pain is much more common than pain on defecation, which is a classic feature of anal fissures
32972
e
Crohn's disease
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.jpeg
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Anal Fissure
Topic
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General Surgery
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A 31-year-old woman attends her GP due to severe pain on defecation. She describes the pain as like passing hard shards of glass. After opening her bowels, she occasionally sees bright red blood when wiping. She opens her bowels once every 2 or 3 days.

What is the most likely diagnosis?
a