ANAL FISSURE TREATMENT

ANAL FISSURE TREATMENT

How is anal fissure treated?

The aims of treatment are two-fold. The first aim is to heal the fissure and the second aim is to identify and treat the underlying cause.

Healing the fissure

A patient is usually prescribed a combination of stool softeners/ laxative, oral painkillers and anal ointment to facilitate easier bowel movement and avoid aggravating the fissure. A topical medication, such as glycerin trinitrate, can be used to aid healing. If the anal fissure persists despite the prescribed treatment, a course of Botox® (botulinum toxin) may be used to relax the anal sphincter muscles temporarily to aid healing.

If a fissure has become chronic, surgery may be necessary. It is important to remember that more than 90% of anal fissures will heal without requiring surgery.

Treating the underlying cause

Once a specific underlying cause is identified, it must be addressed otherwise the anal fissure will recur. The treatment of each cause is individualized.

If the patient suffers from constipation, this must be treated concurrently with the prescribed treatment to heal the fissure. Dietary advice and good toilet habits are essential. This is to prevent recurrence of the anal fissure. Similarly, if the patient is suffering from diarrhoea, it must be controlled. Patients suffering from inflammatory bowel diseases must have treatment to control their condition otherwise the anal fissure will not heal.

Do I need any tests before surgery?

Your doctor may request for some tests before surgery if there is a suspicion that there is an underlying medical problem. This may involve gastrointestinal endoscopy and anorectal physiology studies. Endoscopy is used to rule out medical conditions affecting various parts of the bowel including the stomach, small intestine and colon. Anorectal physiology studies are warranted if there is a dis-coordinated bowel movement pattern which can be corrected by physiotherapy.

Surgery for anal fissure

If an anal fissure persists despite medication, surgery is aimed at reducing the anal muscle pressure to improve blood circulation to the fissure. Very often, there is persistently raised anal muscle pressure due to muscle spasm. This procedure is termed “lateral internal anal sphincterotomy”.

The procedure is performed under light general anaesthesia or lower body anaesthesia as a day surgery procedure. The surgeon cuts a small portion of the lower internal anal sphincter (without risking anal incontinence) and that should allow the anal fissure to heal spontaneously.Recurrence of anal fissure after surgery is rare (less than 10%).

In cases of recurrent anal fissure after previous surgery, a surgeon may have to perform an “advancement flap” surgery to cover the affected fissure with healthy tissue.

What do I need to look out for after surgery?

The patient will have minimal pain even on passing motion. There is a small wound at the edge of the anus after surgery. There may be a small amount of blood stained discharge from the wound for a few days and the wound heals over in 1-2 weeks. Any stitches used are non-permanent and dissolve spontaneously.

Some potential complications to watch out for include wound infection, wound bleeding and anal incontinence. The likelihood of any complication is low.

A wound infection can occur if blood collects under the stitches in the wound and get infected during bowel movement. If that happens, you will need drainage of the infection and antibiotics. Rarely, a small blood vessel that had sealed during surgery re-opens a few days later and bleeds. You may need to have stitching of the vessel if the bleeding does not stop with pressure dressing. Neither of these complications are life-threatening.

Losing control of bowel movement is a nightmare to both patient and surgeon. Even though the risk is very small, it is difficult to treat once it occurs. That is why surgery is only offered if medical treatment fails.

How do I prevent recurrence of anal fissures?

If an underlying medical condition is identified, it is important to get it treated to prevent recurrence of anal fissure. For patients who develop anal fissures due to chemotherapy, it is unlikely to recur after chemotherapy is completed.

If there is an abnormal bowel movement pattern diagnosed, this should be corrected to prevent recurrence of anal fissure as well as other related problems. This can be done through a combionation of medication, dietary advice and pelvic floor physiotherapy (if needed).

DIET IN FISSURE AND PILES

DIET IN FISSURE AND PILES

Add fiber-rich foods to your diet to help ease the constipation by softening bowel movements. 

When eating foods like whole grain bread, multi-grain cereals and fresh produce, remember to drink plenty of water along with the fiber to help it move more easily through your digestive system. Fiber absorbs water, so if you aren't drinking between 6 and 8 glasses of water per day while consuming a lot of fiber, it can get backed up and cause worse constipation.

·         Some fiber-rich foods can make people gassy which, if you are nursing your baby, can also make your baby gassy. You'll need to experiment with the fiber-full foods you add to your diet, removing those that make you too bloated and gassy.

·         Substitute a glass of apple or prune juice for one glass of water to help move things along. Also, an herbal stool-softening tea may help, but if nursing, consult your physician first.

Get Plenty of Fiber

Passing large, hard, or dry stools due to constipation can result in an anal fissure. Getting plenty of fiber in your diet -- especially from fruits and vegetables -- can help prevent constipation.

Aim to consume 20 to 35 grams of fiber per day. To avoid bloating and gas, increase your fiber intake gradually until you notice softer, more frequent bowel movements. Also, be sure to drink plenty of liquids when increasing fiber.

Foods that are good sources of fiber include:

• wheat bran
• oat bran
• whole grains, including brown rice, oatmeal, popcorn, and whole-grain pastas, cereals, and breads
• peas and beans
• seeds and nuts
• citrus fruits
• prunes and prune juice

If you can’t get enough fiber through you diet, try fiber supplements. To avoid gas and cramping, work your way up to the recommended dose over a few days and be sure to take fiber supplements with plenty of liquids.

Stay Hydrated

Avoiding dehydration is important for avoiding constipation. Drinking plenty of liquids adds fluid to your system, which can make stools softer and easier to pass. Be sure to increase your fluid intake even more as the temperature rises or as you become more physically active.

Not all beverages are recommended for preventing dehydration. Excessive alcohol consumption can actually contribute to dehydration. Also, although a caffeinated beverage may help stimulate your bowels, drinking too much caffeine can also lead to dehydration.

Exercise

One of the most common causes of constipation is a lack of exercise and physical activity. Exercise for at least 30 minutes each day, or 150 minutes a week, to help keep your digestive system moving and in good shape.  

Don't Ignore Your Urge to Go

If your body tells you that it's time to have a bowel movement, don't put it off for later. Waiting too long and too often can weaken the signals that let you know it's time to go. The longer you hold stool, the dryer and harder it can get, which makes it more difficult to pass.

Practice Healthy Bowel Habits

Healthy bowel habits can help reduce constipation and strain on the anal canal. Perform these habits regularly to lower your risk of developing a painful anal fissure:

• When using the bathroom, give yourself enough time to pass bowel movements comfortably. But don't sit on the toilet too long.
• Don’t strain while passing stools.
• Keep the anal area dry.
• Be sure to gently clean yourself after each bowel movement.
• Use soft, dye-free, and scent-free toilet paper or wipes.
• Get treatment for prolonged diarrhea.

If you have underlying conditions that contribute to anal fissures -- Crohn’s disease or IBS, for example -- stay on top of your treatment.

IS FISTULA DANGEROUS

Definition

A Fistula is a permanent abnormal passageway between two organs in the body or between an organ and the exterior of the body.

Description

Fistulas can arise in any part of the body, but they are most common in the digestive tract. They can also develop between blood vessels and in the urinary, reproductive, and lymphatic systems. Fistulas can occur at any age or can be present at birth (congenital). Some are life-threatening, others cause discomfort, while still others are benign and go undetected or cause few symptoms. Diabetics, individuals with compromised immune systems (AIDS, cancer) and individuals with certain gastrointestinal diseases (Crohn's disease, inflammatory bowel disease) are at increased risk of developing fistulas.

Fistulas are categorized by the number of openings they have and whether they connect two internal organs or open through the skin. There are four common types:

• Blind fistulas are open on one end only.
• Complete fistulas have one internal opening and one opening on the skin.
• Horseshoe fistulas are complex fistulas with more than one opening on the exterior of the body.
• Incomplete fistulas are tubes of skin that are open on the outside but closed on the inside and do not connect to any internal structure.

Fistulas of the digestive tract

Anal and rectal fistulas develop in the wall of the anus or rectum. They connect the interior of the body to one or several openings in the skin. Anal and rectal fistulas almost always begin as an inflammation in an anal gland. The inflammation then moves into muscle tissue and develops into an abscess. In about half of all cases, the abscess develops into a fistula, degrading the muscle until an opening in the skin is created. About 9 people of every 100,000 develop anal fistulas, with men almost twice more likely to develop the condition than women. Although they may develop at any age, the average age for the development of anal fistulas is 38.

Intestinal fistulas can develop in both the large and small intestine. They are commonly associated with diseases such as inflammatory bowel disease(IBD) and Crohn's disease.

Tracheoesophageal fistulas (TEF) are usually birth defects. The windpipe, or trachea, is abnormally connected to the esophagus. This allows air to enter the digestive system and makes it possible to breathe food into the lungs (aspiration). In many cases, the esophagus is also incomplete, causing immediate feeding problems. There are several types of TEFs categorized by where the fistula is located and how the esophagus and trachea are connected, but all are life-threatening and require prompt surgery to repair. TEFs occur in about one of every 1,500-3,000 births.

Fistulas of the urinary and reproductive tract

The most common type of fistula involving these systems is a vesicovaginal fistula, in which the woman's vagina is connected to the urinary bladder. This causes leakage of urine from the vagina and results in frequent vaginal and bladder infections. Fistulas may also develop between the vagina and the large intestine (a enterovaginal fistula) so that feces leaks from the vagina. Although both these types of fistulas are uncommon in the developed world, they are common in poor developing countries and result from long, difficult labor and childbirth, especially in very young girls. As a result, they are sometimes referred to as obstetric fistulas.

Some experts suggest that in parts of Africa, as many as 3-4 women develop these fistulas out of every 1,000 births. Others estimate that as many as 2 million women worldwide are living with unrepaired obstetric fistulas. If left unrepaired, obstetric fistulas cause women to constantly leak urine and feces. As a result, they become social outcasts, causing them extreme hardship and psychological trauma.

Fistulas of the circulatory system

Arteriovenous fistulas (AVF) can develop between an artery and a vein in any part of the body. These fistulas vary in size, length, and frequency. Arteries contain blood carrying oxygen to all parts of the body, while veins carry blood that has given up its oxygen back to the lungs. Connections between arteries and veins cause changes in blood pressure that result in abnormal development of the walls of the arteries and abnormal blood flow. Arteriovenous fistulas that are present at birth are sometimes referred to as arteriovenous malformations(AVMs). Many arteriovenous fistulas are present, but not evident at birth, and become obvious only after trauma. AVFs can also be acquired from penetrating trauma.

Causes and symptoms

The causes and symptoms of fistulas vary depending on their location. Anal and rectal fistulas are usually caused by an abscess. Symptoms include constant throbbing pain and swelling in the rectal area. Pus is sometimes visible draining from the fistula opening on the skin. Many individuals have a fever resulting from the infection causing the abscess.

Vaginal fistulas are caused by infection and trauma to the tissue during childbirth. They are easily detected, because the woman smells unpleasant and leaks urine or feces through her vagina. Rarely these fistulas may develop as a complication of hysterectomy.

Tracheoesophageal fistulas are the result of errors in the development of the fetus. They are evident at birth, because the infant is unable to swallow or eat normally and are considered a medical emergency that requires surgery if the infant is to survive.

Arteriovenous fistulas are most often congenital defects. Symptoms vary depending on the size and location of the fistula. Often the skin is bright pink or dark red in the area of the fistula. Individuals may complain of pain. The pain is a result of some tissues not receiving enough oxygen because of abnormal blood flow.

Diagnosis

Tests use to determine the presence of a fistula vary with the location of the fistula. When there is an opening to the outside, the physician may be able to see the fistula and probe it. Various imaging studies such as x rays, CT scans, barium enemas, endoscopy, and ultrasonography are used to locate less visible fistulas.

Prognosis

The outcome of fistulas depends on the type and cause of the condition. Surgical repair of obstetric fistulas is almost always successful. Unfortunately, many women in developing countries do not have access to this type of surgery. Treatment of anal and rectal fistulas is almost always successful, although fistulas may recur in up to 18% of individuals. The outcome of surgery on TEFs is highly variable, especially since infants born with this condition often have other developmental abnormalities that may affect the outcome of fistula repair. The degree of successful repair of arteriovenous fistulas depends on their size and location. Uncontrolled bleeding is the most common complication of surgery to repair AVFs.

Prevention

Obstetric fistulas are the only preventable fistulas. These can be prevented with good prenatal and childbirth care and by avoiding pregnancyin very young girls. Although anal and rectal fistulas are not preventable, their damage can be minimized by prompt drainage and treatment.

Now keep in mind that most of the time anal fistulas are not dangerous. They can, however, be extremely painful and can be irritating mostly because of pus drain. Surgery can be done, of course, to help repair the problem. Although this is not necessary, a lot of people choose to do this just to get rid of the discomfort that they feel from it.

The symptoms of having anal fistulas are very easy to spot. Most of the time you will have pain, discharge and itching. Now keep in mind that the discharge that comes from this can be either bloody or purulent. If the abscess becomes infected then you can have some other symptoms that will go along with it as well.

Now as said above, sometimes anal fistulas can become infected. When this happens, the area will require cleaning. You will know if the area has become infected, because you will feel swelling in the area. If you think your abscess has become infected, you should contact your doctor right away and ask what he can do to help. Most of the time, when they become infected, antibiotics are given out. This will help the person get over the infection quickly, and it will also help the abscess to heal a lot quicker.

Overall, this is normally not a problem that you should have to visit a doctor about. However, at times, the pain becomes too much for people to handle on their own and seeing a doctor can bring some relief to the problem. Your doctor may be able to give you some other medications or offer you some other options to help speed this process along much quicker if you do not think that you will be able to bear the pain. Some people are able to, but some people simply cannot do it.

Keep in mind that these kinds of problems can happen to anyone, meaning that just because you get one of these does not mean that you’re doing anything wrong. Sometimes things like this just seem to happen to the body. The best thing that you can do is learn how to deal with these kinds of problems so you can fix them once they happen.

POSSIBLE TREATMENT OF FISTULAS

Treatment

Anal and rectal fistulas are treated by draining the pus the infected area. The individual also is usually given antibiotics to help prevent recurrence of the abscess. If this fails to heal the fistula, surgery may be necessary.

Intestinal fistulas are treated first by reducing the inflammation in the intestine and then, if necessary with surgery. Treatment varies considerably depending on the degree of severity of symptoms the fistula causes. TEFs are always treated with surgery. Obstetric fistulas must also be repaired with surgery. The treatment of arteriovenous fistulas depends on the size and location of the fistula and usually includes surgery.

Anal fistulas do not generally harm the body. They are mainly a nuisance with some pain or discomfort and irritating intermittent discharge of blood, pus or stool. They can form recurrent abscesses which may require drainage under local anaesthetic.

Most of the time the diagnosis of fistula is made on the basis of classical clinical history and physical findings. Examination of the rectum may show an opening of the fistula onto the skin, the area may be painful on examination, there may be redness, a discharge may be seen or it may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula.

Treatment of the fistula depends on the presentation of the problem. If there is active infection or abscess then it needs to be treated with drainage of the pus and antibiotics. Once the infection is cleared the fistula can be treated surgically. If it is difficult to get rid of the infection then long term drainage can be established by inserting a seton – a length of suture material or thin rubber tubing is looped through the fistula which keeps it open and allows pus to drain out.

The treatment aim should be to prevent recurrence of fistula. Treatment depends on where the fistula lies, and which parts of the anal sphincter it crosses.

There are several options. Doing nothing – a drainage seton can be left in place long-term to prevent problems. But this does not cure the fistula. Fistula can be layed open under anaesthetic. Once the fistula has been layed open it will be packed on a daily basis for a short period of time to ensure that the wound heals from the inside out. Depending on the depth of the fistula, this option may affect continence if the fistula involves sphincter muscles. Most fistulas are superficial and can be layed open under local anaesthetic without much problem with continence.

Other methods of treating fistula are: using fibrin glue injection, using fistula plug, creating a flap to cover the internal fistula opening and using a seton to cut through the deep fistulous tract. Each method has advantages and disadvantages.

Some fistulas are very difficult to treat if they are caused by inflammatory bowel disease like Crohn’s disease. Any patient with recurrent fistula should be investigated for inflammatory bowel disease. Otherwise, most fistulas can be cured with patience and perseverance.

PILES, FISSURES ANAD FISTULAS

Hemorrhoids also called piles, are swollen and inflamed veins in your anus and lower rectum. Hemorrhoids may result from straining during bowel movements or from the increased pressure on these veins

Types

A] External piles- present as a swelling outside the anus with irritation and itching. These can be painful sometimes and usually do not bleed.

B] Internal piles- Internal piles are usually not painful but these bleed when they are irritated such as during the passage of hard stools. They can be classified into four grades:

• Grade 1 piles are small swellings on the inside lining of the anus. They cannot be seen or felt from outside the anus.

• Grade 2 piles are partly pushed out (prolapse) from the anus when you go to the toilet, but quickly 'retract back' inside again.

• Grade 3 piles hang out (prolapse) from the anus and are felt as one or more small, soft lumps that hang from the anus. However, they can be pushed back inside the anus with a finger.

• Grade 4 piles permanently hang down from within the anus, and cannot be pushed back inside. They can sometimes become quite large

 

    Primary haemorrhoids:  These are three in number seen at 3, 7 & 11 o’clock positions.

Secondary haemorrhoids: Presence of additional haemorrhoids in between the primary piles is known as the secondary piles.

Signs and symptoms

Painless bleeding during bowel movements — you might notice small amounts of bright red blood on your toilet tissue or in the toilet bowl

·         Itching or irritation in your anal region

·         Pain or discomfort

·         Swelling around your anus

·         A lump near your anus, which may be sensitive or painful

·         Leakage of feces

Haemorrhoids symptoms usually depend on the location.

 Internal hemorrhoids lie inside the rectum.You usually can't see or feel these hemorrhoids, and they usually don't cause discomfort.

But straining or irritation when passing stool can damage a hemorrhoid's delicate surface and cause it to bleed. Occasionally, straining can push an internal hemorrhoid through the anal opening. This is

known as a protruding or prolapsed hemorrhoid and can cause pain and irritation.

External hemorrhoids are under the skin around your anus. When irritated, external hemorrhoids can itch or bleed. Sometimes blood may pool in an external hemorrhoid and form a clot (thrombus), resulting in severe pain, swelling and inflammation.

Causes

The veins around your anus tend to stretch under pressure and may bulge or swell. Swollen veins — hemorrhoids — can develop from an increase in pressure in the lower rectum. Factors that might cause increased pressure include:

·         Straining during bowel movements

·         Sitting for long periods of time on the toilet

·         Chronic diarrhoea or constipation

·         Obesity

·         Pregnancy

·         Dietary habits: elimination of cereal fibres from the diet results considerably in the high incidence of chronic constipation and ultimately haemorrhoids

·         Anal inter)      Hereditary:  Some defect in the venous structure has been held responsible. e.g. congenital weakness of the walls of vein.course

·         Constipation: Straining in constipated persons results in the engorgement of internal haemorrhoidal veins, giving rise to the disease piles.

2] Anal Fistula

WHAT IS AN ANAL FISTULA?

Anal fistula, or fistula-in-ano, is an abnormal connection or channel like structure, between the surface of the anal canal and the exterior perianal skin. Anal fistulae originate from the anal glands, which are located between the two layers of the anal sphincters and which drain into the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can eventually point to the skin surface. The tract formed by this process is the fistula. Ancient Ayurveda surgeon, Susruta has described five types of Bhagandara(Sataponak, Ustragriwa, Parisrabi, Sambukawarta, Unmargi). They have been classified according to the vitiation of the three doshas and the shape & site of the fistula tract.

CAUSES OF FISTULA?

Anal fistulas commonly occur due to an anal abscess.

An abscess is a collection of pus and infected fluid. An anal abscess usually develops after a small gland, just inside the anus, becomes infected with bacteria.

A fistula may occur if an abscess has not completely healed, or if the infected fluid has not been entirely drained away.

An anal fistula may also develop as a result of:

·         a growth or ulcer (painful sore)

·         a complication from surgery

·         a congenital abnormality (a health problem that you were born with)

Anal fistulae are also a common complication of conditions that result in inflammation of the intestines. Some of these conditions include:

·         Irritable bowel syndrome (IBS): a chronic (long-term) disorder that affects the digestive system, causing abdominal pain, diarrhoea and constipation.

·         Diverticulitis: the formation of small pouches that stick out of the side of the large intestine (colon), which become infected and inflamed.

·         Ulcerative colitis: a chronic condition that causes the colon to become inflamed and can cause ulcers to form on the lining of the colon.

·         Crohn's disease: a chronic condition that causes inflammation of the lining of the digestive system.

SYMPTOMS OF FISTULA

Anal fistulae can present with many different symptoms such as:

·         Pain

·         Discharge - either bloody or purulent

·         Pruritus ani– itching around the anus

·         Systemic symptoms if abscess becomes infected

DIAGNOSIS OF FISTULA

Diagnosis is by examination, either in an outpatient setting or under anaesthesia. The examination can be an Anoscopy.

Possible findings:

·         The opening of the fistula onto the skin may be seen

·         The area may be painful on examination

·         There may be redness

·         A discharge may be seen

·         It may be possible to explore the fistula using a fistula probe (a narrow instrument) and in this way it may be possible to find both openings of the fistula

ANAL FISSURES

What is a fissure?

An anal fissure is a small tear in the skin that lines the anus. An anal fissure may occur when you pass hard or large stools during a bowel movement. An anal fissure typically causes pain and bleeding with bowel movements.

Anal fissures most often affect people in middle age, but fissures also are the most common cause of rectal bleeding in infants. Most anal fissures heal within a few weeks with treatment for constipation, but some fissures may become chronic

COMMON CAUSES OF ANAL FISSURES

Anal fissures can be caused by trauma to the anus and anal canal. The cause of the trauma can be one or more of the following:

·         Chronic constipation

·         Straining to have a bowel movement, especially if the stool is large, hard, and/or dry

·         Prolonged diarrhea

·         Anal stretching

·         Insertion of foreign objects into the anus

Other causes of anal fissures (other than trauma) include:

·         Longstanding poor bowel habits

·         Overly tight or spastic anal sphincter muscles (muscles that control the closing of the anus)

·         Scarring in the anorectal area

·         Presence of an underlying medical problem: such as Crohn’s disease and ulcerative colitis; anal cancer; leukemia; infectious diseases (such as tuberculosis); and sexually transmitted diseases (such as syphilis, gonorrhea, Chlamydia, chancroid, HIV)

·         Decreased blood flow to the anorectal area

SYMPTOMS OF ANAL FISSURE

Signs and symptoms include:

·         Pain during, and even hours after, a bowel movement

·         Constipation

·         Blood on the outside surface of the stool

·         Blood on toilet

·         A visible crack or tear in the anus or anal canal

·         Burning and itch that may be painful

·         Discomfort when urinating, frequent urination, or inability to urinate

·         Foul-smelling discharge

·          

RISK FACTORS FOR ANAL FISSURES

Factors that may increase your risk of developing an anal fissure include:

·         Infancy. Many infants experience an anal fissure during their first year of life, although experts aren't sure of the reason.

·         Aging. Older adults may develop an anal fissure partly because of slowed circulation, resulting in decreased blood flow to the rectal area.

·         Constipation. Straining during bowel movements and passing hard stools increase the risk of tearing.

·         Childbirth. Anal fissures are more common in women after they give birth.

·         Crohn's disease. This inflammatory bowel disease causes chronic inflammation of the intestinal tract, which may make the lining of the anal canal more vulnerable to tearing

PREVENTION OF ANAL FISSURES

For fissures in adults:

·         Keep the anorectal area dry

·         Wipe the area with soft materials, a moistened cloth, or cotton pad; avoid rough and scented toilet paper

·         Promptly treat all occurrences of constipation and diarrhea

·         Avoid irritating the rectum

COMPLICATIONS OF ANAL FISSURES

Complications of anal fissure can include:

·         Anal fissure that fails to heal. An anal fissure that doesn't heal can become chronic, meaning it lasts for more than six weeks.

·         Anal fissure that recurs. If you've experienced anal fissure once, you have an increased risk of another anal fissure.

·         A tear that extends to surrounding muscles. An anal fissure may extend into the ring of muscle that holds your anus closed (internal anal sphincter). This makes it more difficult for your anal fissure to heal. An unhealed fissure may trigger a cycle of discomfort that may require medications or surgery to reduce the pain and repair or remove the fissure.