12/10/2023 0 Comments Anal fissure with sentinel pileThe physical exam of the patient with an anal fissure should involve the most comfortable position for the patient. Patients with underlying granulomatous diseases such as Crohn disease, among others, will sometimes provide a history of chronic anal pain during defecation that is intermittent rather than constant over an extended period. Associated constipation is the most common factor involving chronic anal fissures, and patients will provide a longstanding history of hard stools. Patients with chronic anal fissures will have a history of painful defecation with or without rectal bleeding that has been ongoing for several months to possibly years. Therefore, a thorough physical exam should be performed to delineate between the two. Often, acute anal fissures may be misdiagnosed as external or internal hemorrhoids. The pain usually persists for hours after defecation. Patients with acute anal fissures present with complaints of anal pain that is worse during defecation. At times, there is associated bleeding with bowel movements but usually not frank hemorrhage. Anterior fissures are rare and are associated with external sphincter injury and dysfunction. The cause of this other location is not well known. ![]() Other locations of anal fissures, such as lateral fissure, are indicative of an underlying etiology (HIV, tuberculosis, Crohn disease, ulcerative colitis, among others). The perfusion of the anal canal has an inverse relationship to sphincter pressure. It is well known that the most common location of an anal fissure is the posterior midline because this location receives less than half of perfusion compared to the rest of the anal canal. Together with spasms of the sphincter, this creates severe pain with bowel movements, as well as some rectal bleeding. ![]() ![]() The tear can sometimes be deep enough to expose the sphincter muscle. Due to the high pressures in this area, it can result in the delayed healing secondary to ischemia. It is a very sensitive area to microtrauma and can tear with repetitive trauma or increased pressure. The location is inferior to the dentate line. The anoderm refers to the epithelial component of the anal canal.
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