A Case Of Anal Fissure - Similima

A Case of Anal Fissure
Presented by
Dr. K.Shiva Kumar, M.D
A Case Of Anal Fissure
Presented by
Dr.K.Shiva Kumar
M.D (Sch)
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Patient Data
�Name; Sharifa
�Age ; 38ys.
�Sex ; Female.
�Address ; Puthiyangadi.
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Presenting Complaints
�Pain in Rectum during and after stool
since 3years. by moving
about.
�Constipation since 3years.
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History of presenting complaints
� Complaints started 3years back as after
inproperly operated haemorrhoids,
� Complaints started slowly, developed
insidiously.
� Pain so severe, burning cutting type, during pain
pt cannot sit, frequent urging for stool, straining
at motion agg the pain, pt try to remove the stool
mechanically, to relieve pain pt puts ice pieces
into the anus, even though there was no relief.
� Occasionally trace streaks of blood in stool.
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PHI
� Pt had endometriosis, adenomyosis and
hysterectomy done before 3months back.
� Pt had lt sided ovarian cyst, and lt ovary has
removed while hysterectomy.
� Pt also has pulmonary stenosis, pt also had
hystory of rheumatic fever at the age of 16years.
� Haemorrhoids begins during 2nd pregnency and
underwent ayurvedic surgery 3years back.
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Treatment hystory
�Pt taken allopathic and homoeopathic and
ayurvedic treatment without much
improvement.
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Family history
�Oral, GI cancer history in close relatives.
�Father died with heart complaint.
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Personal history
�B/B at koyilandy
�Studied upto 10 th stand.
�Has 2 children, elder one suffering from
allergic asthma.
�Financially stable.
�No addictions and habbits.
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Menstrual history
�Before hysterectomy menses usually late,
scanty, LBA, pain in limbs associated.
�Now there is no menses.
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Obstetrical history
�G2P2L2A0D0
�No Complications during both
pregnencies.
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Mental Generals
�Pt is very impatient.
�Irritable during complaints,
�Patient is usually very friendly but when
complaints occur pt become irritable,
impatient, depair of recovery.
�Wants to be alone.
�Very sensitive to comments made by
other.
�Jelous, egotic.
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�Pt wont get anger easily, if pt got anger
very difficulty to control, pt will throw the
things, tears the cloths. Violent burst of
anger.
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Physical Generals
�Appetite moderate.
�Thirsty pt.
�B/M obstinate constipation, frequent
urging but difficult to pass it, severe pain
develop on straining in toilet,
�Stool large, very dry and hard, passing
stool relieves the pt temporarily.
�Sleep- disturbed.
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�Hot pt , hot sensation all over the body.
�Desire fanning always.
�Prefers mild warm food and drinks.
�Desire tea.
�Desire juicy things.
�General left sided complaints.
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Genaral Examination
�Pt is mild over weight, fair, robust
constitution.
�Pulse ;80/m.
�Heart rate; 80/m.
�BP ; 130/90mmhg.
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Examination
�Local examination; Very dry anal around
area, cracks visible, sentinal pile visible.
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Investigation
�Not done particularly.
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Provisional diagnosis
�By clinical symptoms, and history of past
illness Provisionally diagnosed as
‘Fissure in ani’
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Miasmatic Diagnosis
�Sycosyphilic.
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Toatality of symptoms
� Pain in Rectum during and after stool by moving about. Stool removes
mechanically.
� Constipation obstinate.
� Frequent urging for stool, stool very hard and
dry,
� Pt is very impatient.
� Irritable during complaints,
� Patient is usually very friendly but when
complaints occur pt become irritable, impatient,
depair of recovery.
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�Wants to be alone.
�Very sensitive to comments made by
other.
�Jelous, egotic.
�Pt wont get anger easily, if pt got anger
very difficulty to control, pt will throw the
things, tears the cloths. Violent burst of
anger.
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�Appetite moderate.
�Thirsty pt.
�B/M obstinate constipation, frequent
urging but difficult to pass it, severe pain
develop on straining in toilet,
�Stool large, very dry and hard, passing
stool relieves the pt tempororly.
�Sleep- disturbed.
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�Hot pt , hot sensation all over the body.
�Desire fanning always.
�Prefers mild warm food and drinks.
�Desire tea.
�Desire juicy things.
�General left sided complaints.
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Rubrics Selected
� RECTUM - PAIN - stool - during
� abrom-a. aesc. aeth. agath-a. aids. aloe alum-sil. Alum. alumn. am-c. am-m. ambr. amp. anac. androc. Antc.
anthraq. aq-mar. arizon-l. ars-s-f. ARS. asaf. Asar. aur-ar. aur-s. aur. bar-c. bar-m. bar-s. bell. Berb.
brach. brom. Bry. calc-p. calc-s. calc-sil. CALC. canth. caps. carb-an. Carb-v. Carbn-s. carl. casc. Caust.
cham. Chel. chin. chinin-ar. chord-umb. cimx. COLCH. COLL. coloc. con. cop. crot-t. cuph. Cupr. dros.
falco-pe. ferr-ar. ferr-p. ferr. Fl-ac. GRAPH. grat. hell. hep. hyos. Ign. Kali-ar. Kali-bi. kali-c. kali-m. kali-p.
kali-s. kali-sil. kola kreos. Lac-c. lac-d. Lach. lat-m. lil-s. Lil-t. LYC. lyss. mag-m. manc. mang. med. melalalt.
merc-i-r. Merc. mez. mur-ac. nat-c. nat-m. nat-s. NIT-AC. nux-m. nux-v. oci-sa. Ox-ac. Paeon. ph-ac.
phos. plac-s. plan. plat. Plb. PODO. positr. puls. RAT. rhus-t. Ruta sabin. Sanic. Sep. SIL. stann.staph
stront-c. suis-em. sul-ac. SULPH. sumb. Syph. tarent. Thuj. Tub. verat. zinc-p. Zinc.
� RECTUM - PAIN - stool - after
� abrom-a. adam. AESC. agar. ALOE alum. Alumn. Am-c. Am-m. androc. apoc. ars-s-f. Ars. asaf. asar. Bac.
bar-c. bar-s. bell. Berb. bov. Brom. cact. calc-p. calc-s. calc-sil. calc. canth. Carb-v. carbn-s. carl. casc.
cassia-s. caust. cham. cic. cob. cocc. Colch. crot-t. cystein-l. dios. elaps Graph. grat. hell. hydr. hydroph.
IGN. ind. Kali-ar. kali-bi. kali-c. kali-m. kali-p. kali-s. Kalm. Lach. lil-t. lob. Lyc. mag-m. manc. melal-alt.
merc-c. merc-i-r. MERC. mez. MUR-AC. Nat-c. nat-m. nat-p. NIT-AC. nux-v. paeon. petr. phos. Podo. positr.
Psor. ptel. puls. RAT. rhus-t. rhus-v. Ruta sabad. seneg. Sep. sil. staph. stront-c. Sul-ac. SULPH. sumb.
suprar. symph. tarent. thuj. trios. verat-v.
� MIND - SENSITIVE - external impressions, to all
� anac. arg-met. arn. ars. aur. bac. bell. Canth. caps. carc. castm. cham. chin. choc. clem. Cocc. coff. Colch.
cypra-eg. dys. gaert. gard-j. hep. hydrog. Iod. irid-met. just. kali-p. kola lac-c. lach. limest-b. lyss. mag-m.
nat-m. Nit-ac. Nux-v. olib-sac. ph-ac. PHOS. positr. ptel. sanic. sil. Staph. stry. suis-em. sul-i.
� MIND - JEALOUSY
� Aml-ns. anac. anan. Apis arg-n. ars. Aur-m-n. bamb-a. bufo calc-p. Calc-s. camph. Cench. cham. Cocain.
cocc. coff. coloc. crot-c. cystein-l. gal-ac. gels. haliae-lc. ham. HYOS. ign. ilx-a. ip. kali-act. kali-ar. kali-c.
kali-p. kali-s. Kola lac-c. lac-leo. LACH. lil-t. lyc. Med. merc. morg-g. nat-m. nat-sil. Nux-m. NUX-V. op. phac.
pin-con. plat. positr. Puls. raph. sabad. sacch. sal-fr. sep. Staph. Stram. sulph. ther. thuj. verat.
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� MIND - EGOTISM
� act-sp. alco. Alum. anac. anan. androc. anh. aq-mar. arn. aur-m-n. Aur-s. aur. bufo Calc. cic.
cich. cimic. crot-t. cur. des-ac. dream-p. eric-vg. fl-ac. granit-m. hydrog. ignis-alc. ina-i. Iod.
lac-leo. Lach. Lyc. marb-w. Med. merc. nicc-met. Nux-v. Pall. par. phos. PLAT. plb. positr.
ribo. sal-fr. sal-l. senec. Sil. staph. stram. Sulph. Verat.
� GENERALS - FOOD and DRINKS - juicy things - desire
� abrom-a. aloe Ant-t. ars. atis. bamb-a. chin. choc. gran. graph. hippoc-k. ketogl-ac. kola lacleo.
mag-c. med. nat-ar. nux-v. oci-sa. PH-AC. phos. pieri-b. positr. puls. sabad. Sabin. salfr.
sangin-n. sars. sol staph. sul-ac. verat.
� GENERALS - SIDE - left - then right side
� acon. adam. all-c. aloe androc. arg-n. benz-ac. brom. bros-gau. calc-p. calc. Colch. cupr.
dulc. elaps ferr. form-ac. Form. hed. hydrog. Iod. ip. kali-c. kreos. lac-c. LACH. naja neon
nit-m-ac. phyt. podo. psil. rad-br. rhus-t. sabad.
� GENERALS - FOOD and DRINKS - tea - desire
� abrom-a. alum. aster. bung-fa. calc-s. Casc. chen-a. Chin. coca-c. des-ac. galeoc-c-h. ham.
hep. hydr. kali-p. kola lac-h. lavand-a. lepi. luna lyss. musa nat-m. nat-sil. nux-v. olib-sac.
plac-s. podo. positr. Puls. pyrus rhus-g. Sacch. sel. sep. staph. suis-em. thuj. uran-n.
� RECTUM - CONSTIPATION - removed mechanically; stools have to be
� RECTUM - PAIN - sitting - while
� Aesc. Aloe am-m. ammc. ars. bar-c. berb. calc. cann-s. caust. chel.
cocc. coloc. cycl. euphr. ham. hydrog. LYC. Mang. merc-cy. Mur-ac.
Ph-ac. phos. RAT. Ruta sars. SEP. staph. sulph. ther. thuj.
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�Nux – 15/8
�Lach – 15/7
�Staphy-11/7
�Lyco -11/6
�Sulph-10/6
�Nit.acid-11/4.
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On 4-7-09
�Rx; 1.Nux.vom 200 1dose.
2.S.l for 2days.
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On 7 th July
�Pt came and reported no change in
condition severe pain , constipation ,pt can
not sit also, pt also during pain she is
becoming mad, violent anger.
Rx;1.Staphysagria 200 1dose.
2. S.l for 1week.
Pt asked to wait for atleast 1week,
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On 8 th july
�Pt called me and told about large faecal
matter passed out, pain also greatly
relieved. now pt is very comfortable.
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On 15 th july
�Pt came and reported regularly passing
stool no pain and constipation,
Rx; 1.S.L for 2weeks.
2.BT for 2weeks.
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On 30 th july
�Pt came and reported no pain, passing
stool comfortly, no other complaints
Rx; 1. S.l for 2weeks
2. BT for 2weeks.
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On 15 th august
�Pt came and reported no complaints,
Rx; 1.S.l for 2weeks.
2. BT for 2weeks.
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Staphysagria
�It covers maism ie sycosyphilitic.
�Multiple pathology in middle aged female,
mainly related to uterus.
�Mental symptoms suited exactly.
�Right time pt receives right prescription,
that’s why after 50days also no return of
complaints till now.
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Anal Fissure
�Synonym ; Fissure in ano .
�It is an elongated ulcer in the long axis of
the lower anal canal.
�Location ; The site of election for an anal
fissure is the middle line posteriorly (90%
over all) . The next most frequent situation
is the midline anteriorly.
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Aetiology ;
�An incorrectly performed operation for
haemorrhoids in which too much skin is
removed . This results in anal stenosis and
tearing of the scar when a motion is
passed.
�Inflamatory bowel diseases .
�Sexually transmitted disease .
�Tuberculosis .
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Pathology ;
�An anal fissure is either acute or chronic.
The upper internal end of the fissure stops
at the dentate line . Because the fissure
occurs in the stratified sensitive epithelium
of the lower half of the anal canal, pain is
the most prominent symptom .
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Acute anal fissure;
�It is a deep tear through the skin of the
anal margin extending into the anal canal.
There is little inflammatory induration or
edema of its edges .
�There is accompanying spasm of the anal
sphincter muscle.
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Chronic anal fissure ;
�It is charecterised by inflamed indurated
margins and a base consisting of either
scar tissue or the lower border of the
internal sphincter muscle.
�The ulcer is canoe shaped at the inferior
extremity there is a tag of skin , usually
oedematous.
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� This tag is known as a sentinel pile- sentinel –
because it guards the fissure. There may be
spasm of the involuntary musculature of the
internal sphincter.
� Infection is common and may be severe ending
in abscess formation. A cutaneous fistula may
follow.
� Chronic fissure in ano may have a specific
cause- often a granulomatous infection- eg-
chron’s disease. Specific fissures of this type are
often less painful.
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Clinical features;
�1.Pain during and after stool.
�2.Bright red bleeding .
�3.Mucous discharge .
�4.Constipation .
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�The condition is more common in women
and generally occur during the meridian of
life.
�If it uncommon in the aged because of
muscular atony, where as anal fissure is
not rare in children is sometimes
encountered during infancy and may
cause aquired megacolon.
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�Pain is the symptom –sharp, agonising
pain starting during defeacation , often
over whelming in intensity and lasting for
an hour or more.
�It ceases suddenly and the sufferer is
comfortable until the next action of bowel .
�It tends to become constipated rather
then go through the agony of defeacation.
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�Bleeding –this is usually slight and consist
of bright streaks on the stools or the
paper.
�Discharge; A slight discharge
accompanies fully established.
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On Examination ;
� In cases of some standing a sentinel skintag can
usually be displayed. This together with a typical
history and a tightly closed, puckred anus, is
almost pathognomonic of the condition.
� By gently parting the margins of the anus, the
lower end of the fissure can be seen.
� In early cases the edges of the fissure are
impalpable, in fully established cases, a
charecterestic crater which feels like a button
hole can be palpated.
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Treatment ;
� A. Acute ulcers; with short history usually
heals with conservative treatment like oral pain
medication , stool softner may be used,
� Nitric oxide is a neurotransmitter which induces
relaxation of the internal sphincter, Glyceryl
trinitrate is a nitric acid donor and is applied as
an ointment to the anal canal to produce the
relaxation of the internal sphincter.
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B.Chronic ulcer ;
�1. Anal dilatation ; Lords procedure of anal
dilatation is the simplest method to dilate
the sphincter of the anal canal.
�2. Posterior sphincterotomy and fissure
ctomy.
�3.Lateral canal sphincterotomy.
�4.Excision of anal ulcer .
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Differential Diagnosis ;
�1.Multiple fissures; In the perianal region
are seen as a complication of skin
disease, inflammatory bowel disease or
anorectal sexually transmitted disease
such as herpes HIV.
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2.Haemorrhoids;
�Are dilated veins occurring in relation to
the anus, such haemorrhoids may be
external or internal .
�External variety is covered by skin, while
the internal haemorrhoids are covered by
mucous membrane, usually commences
at the anorectal ring and ends at the
dentate line.
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Aetiology;
� 1.Heridetory; seen in members of same family,
associated with varicosity of lower limbs.
� 2.Anatomical;The collecting radicles of the
superior haemorrhoidal vein lie unsupported in
the very loose submucous connective tissue of
the anorectum.These veins pass through
muscular tissue and are liable to be constricted
by its contraction during defaecation.
� 3.Exacerbating factors; straining accompanying
constipation or that induced by over purgation is
considered to be a potent cause of
haemorrhoids.
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Clinical features;
�1. Bleeding which charecterestically
occurs on defaecation and is usually bright
red.
�2.Prolapse-Either on straining or all the
time.
�3.Mucous discharge when rectal mucosa
is exposed.
�Pain, Itch, rectal discomfort.
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Signs;
�Anal verge is normal in 1st degree piles, in
second degree there may be hypertrophy
of the anal skin verge sometimes a skin
tag, third degree piles are visible as muco-
cutaneous bulge.
�Diagnosis; A careful history,particularly of
bowel habits is helpful but all patients with
piles should have at least a rigid
sigmoidoscopy.
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2.Peri-anal haematoma ;
� (Thrombosed external pile) An external
haemorrhoids covered by true skin into which
there has been an acute submucous rupture, of
a tributary of the inferior haemorrhoidal venous
plexus.
� Spontaneous resolution may occur with
resorption of the blood clot leaving a redundant
piece of perianal skin, alternatively rupture of the
skin may occur and be associated with the loss
of a small amount of blood and the formation of
an ulcer which slowly heals.
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Clinical Features;
� 1. Pain is of acute onset and often experienced
after straining at defaecation.
� 2. A lump which appears at the anal verge.
� 3. Heamorrhage is in the form of a small amount
of clotted blood when spontaneous rupture
occurs and followed by dramatic relief of pain.
� 4. A lump which is a tense, tender blue swelling
at anal verge.
� 5. An ulcer occurs if spontaneous rupture has
already occured.
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3. Ano-rectal suppuration ;
� Infection of the peri-anal and peri-rectal spaces
with staphylococci, streptococci, E.coli, and
proteus organism may occur.
� Source of infection;
� a. Anal fissure.
� b. A peri anal haemartoma.
� c. A hair follicle, sebaceous or apocrine gland.
� d. Ulcerative colitis. Chron’s disease.
� e. Carcinoma.
� F. Diverticular disease.
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1.Peri anal abscess.;
�Pain situated deep in the buttock is
throbbing in nature and aggravated by
walking, sitting, and defaecation.
�Pyrexia and toxaemia are usually absent.
on digital examination a tender lump is felt
outside the wall of the anal canal and just
beneath the perianal skin.
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2.Ischio-rectal abscess.;
�Pain situated deep in the buttock is
throbbing in nature and is aggravated by
walking, sitting, and defaecation.
� Pyrexia and toxaemia may be present.
�Absence of superficial signs of
imflamation.
�On digital examination there is tender
lump is outside the wall of the anal canal
but extending above the ano rectal ring.
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3.Submucous abscess.-
�Situated in submucosa of anal canal. Pain
which is usually mild but

4.Pelvi rectal abscess.;
�This is rare type of abscess Situated
above the levator ani. It most often follows
pelvic cellulites but it may some times
arise as a complication of ulcerative colitis,
chrons disease, diverticular disease or
rectal carcinoma.
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5. Carcinoma of the Rectum ;
� in very early stage may simulate a fissure in ano. It
may bleed during defaecation even or it may simply
stain the underclothing.
� The pt may endeavour to empty the rectum several
times a day often with passage of blood and
mucus(Spurious diarrhoea).
� The pt often gets up in the morning with an urgent
urge for defaecation.
� In case of annular carcinoma affecting the upper part
of the rectum the patient complaints of increasing
constipation needing increasing dose of purgative and
as a result diarrhoea ensues.
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�It is also due to the fact that hard faeces
irritates the colon leading to diarrhoea.
Pain is a late symptom but pain of colicky
character ,may be experienced.
�One should always perform
sigmoidoscopy, double contrast barium
enema X-ray, colonoscopy and biopsy of
the growth.
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5.Proctalgia fugax ;
� which is charecterised by severe pain arising
from the rectum and occurs at irregular intervals,
The pain is cramp like last for a few minutes and
disappears spontaneously.
� It is often occurs at night, It is said to be seen
more commonly in patients who are in undue
stress or anxiety,
� A more chronic form of the disease has been
termed the levator syndrome and may be
associated with severe constipation.
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6.Pilonidal sinus;
� This occurs in the natal cleft as a discharging
sinus running upwords with lateral, secondarily
infected tracks, hairy individuals are often
affected and 60% of sinuses contain hairs.
� Pilonidal sinuses may also occur in the web
spaces between the fingers and toes, especially
in hairdressers.
� The lesion is probably aquired and infection with
subsequent abscess formation is the
commonest complication.
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