Discussed in this article are the treatment recommendations and surgical interventions for the management of anal fissures, which has been taken from the American College of Gastroenterology (ACG) guideline.

Where are fissures located?

Anal fissures are anorectal structural disorders, which are ulcer-like longitudinal tears in the midline of the anal canal, distal to the dentate line. The majority of idiopathic fissures (90%) are located in the posterior midline, however, it can also occur in the anterior midline. Fissures in lateral positions are of special concern as they can be clues for disease processes such as:

• Crohn's disease
• Tuberculosis
• Syphilis
• Human immunodeficiency virus/acquired immunodeficiency syndrome
• Dermatologic conditions such as psoriasis, anal carcinoma

Acute vs chronic fissure

An acute anal fissure presents as a simple tear in the endoderm, while a chronic fissure is a non-healing anal fissure, lasting more than 8 to 12 weeks.

Chronic fissures are characterised by overhanging edges, oedema, and fibrosis with fibres of the internal anal sphincter, prominently visible on the floor of the fissure.

Medical management of anal fissures

Managing acute anal fissure

Sitz baths and fibre supplements such as psyllium should be the first steps when managing acute anal fissure cases. Almost 50% of acute anal fissure cases heal with sitz baths and fibre supplements, with or without the addition of topical anaesthetics or anti-inflammatory ointments. Apart from healing, these approaches can provide relief from pain and bleeding.

Treatment recommendations for chronic anal fissures

1. Local application of a calcium channel blocker (CCB) should be the initial medical treatment of chronic anal fissure.
2. Botulinum toxin A injections may be attempted in patients in whom CCB fails or as an alternative option to CCB. Botulinum toxin A injection in doses of 5–100 units is reported to have superior healing rates but it is a minimally invasive procedure requiring a needle injection in a sensitive area.
3. Topical nitrate medications may potentiate the effects of botulinum toxin in patients with refractory anal fissure.

Surgical interventions

1. Lateral internal sphincterotomy (LIS) is the surgical treatment of choice for chronic anal fissures that do not heal with nonsurgical measures such as CCB or botulinum toxin A injection.
2. LIS is a procedure in which fibres of the internal anal sphincter muscle are cut up to the apex of the fissure or the dentate line. LIS may be considered in patients with the rectal sparing disease with good resting and squeeze pressures. The procedure can be conducted using general, spinal, or local anaesthesia.
3. When comparing the different approaches, there is no outcome difference between open and closed sphincterotomy – it is advised to follow a minimal-incision approach.
4. Controlled pneumatic balloon dilation has been demonstrated to be a potential alternative to LIS and is said to treat even medically refractory anal fissures without resorting to surgical consultation. But the safety and efficacy of LIS make it a better option.
5. Caution should be exercised when using LIS in patients when anal pressures are not high. This can be evaluated by digital examination only – anal advancement flap repair or a V-Y plasty is recommended.
6. LIS should be used with great caution in cases with Crohn's disease, medical management is recommended in this situation.

Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.