PANCE Blueprint GI and Nutrition (10%)

Anal fissure (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

proctitis

51-year-old with rectal bleeding and abdominal pain (proctitis)

Patient will present with → rectal pain and bleeding which occurs with or shortly after defecation, lasts for several hours, and subsides until the next bowel movement.

Anal fissures are believed to result from laceration by a hard or large stool or from frequent loose bowel movements

  • Trauma (eg, anal intercourse) is a rare cause
  • The fissure may cause internal sphincter spasm, decreasing blood supply and perpetuating the fissure

Diagnosis is made by history and visual inspection

  • Unless findings suggest a specific cause or the appearance and/or location is unusual, further studies are not required.

Treatment includes:

  • Stool softeners
  • Protective ointments, sitz baths
  • Nitroglycerin ointment, topical Ca channel blocker, or botulinum toxin type A injection
Question 1
A 35-year man presents with 1 week history of anal pain that occurs during defecation and subsides after a few hours. He also says he noticed bright-red blood on the toilet paper. He has been constipated for the past 6 months. Gentle perianal examination with inspection of the anal mucosa reveals a posterior midline ulcer. What is the diagnosis?
A
Anal fissure
B
Crohn’s disease
Hint:
Other symptoms would be abdominal pain and prolonged diarrhea. It causes fissures outside the midline. 50% of fissures are painless.
C
Anal carcinoma
Hint:
Atypical and shape of fissure. History of human papillomavirus infection.
D
Tuberculosis
Hint:
History of tuberculosis. Lateral site of fissure.
Question 1 Explanation: 
Posterior midline anal fissure is commonly due to straining due to constipation.
Question 2
Which of the following is a treatment option following failure of conservative treatment for anal fissure?
A
Lateral anal sphincterotomy.
B
Cryosurgery.
Hint:
Is used in treating hemorrhoids
C
Infrared coagulation.
Hint:
Is used in treating hemorrhoids
D
Temporary Thiersch operation.
Hint:
Is used in treating rectal prolapsed.
Question 2 Explanation: 
Operative treatment becomes necessary when conservative treatment fails. The internal sphincter is divided laterally subcutaneously up to the level of the dentate line and the sentinel pile and margins of the fissure excised. Internal sphincterotomy reduces permanently the anal maximum resting pressure by as much as 50% and thereby improves the blood supply to the ischaemic fissure.
Question 3
Which of the following is not a treatment option for anal fissure
A
Topical diltiazem
Hint:
It heals about 65% of fissures with very few side-effects. It heals most fissures that do not heal with GTN.
B
Topical glyceryl trinitrate (GTN) ointment
Hint:
reduces the maximum resting anal pressure of the order of 35%. It relaxes the internal anal sphincter, (via the release of the neurotransmitter nitric oxide) thereby improving the blood supply to the mucosa and ischaemic fissure and leads to its healing in about 60% of patients in 8 weeks.
C
Botulinum toxin
Hint:
It is an exotoxin produced by CI. Botulinum and is a potent neurotoxin. It reduces the myogenic tone and adrenaline-mediated contractile response to sympathetic stimulation of the internal anal sphincter thereby reducing the resting anal pressure, usually by about 25%.
D
Cisapride
Question 3 Explanation: 
Cisapride is a prokinetic agent. It’s not used in the treatment of anal fissure.
Question 4
Which of the following statements concerning anal fissure is not true?
A
Anterior fissures account for about 90% of those encountered in women.
B
Most commonly occur at the posterior midline.
Hint:
See A for explanation
C
Anal advancement flap is a form of treatment.
Hint:
See A for explanation
D
May be due to trauma caused by the strained evacuation of a hard stool.
Hint:
See A for explanation
Question 4 Explanation: 
Anal fissures are linear lesions in the rectal wall most commonly found on the posterior midline. Anterior fissures account for about 10% of those encountered in women.
Question 5
Which of the following is the most appropriate treatment for anal fissure?
A
Sitz baths
Hint:
See E for explanation
B
Topical nitroglycerin ointment
Hint:
See E for explanation
C
Topical silver nitrate
Hint:
See E for explanation
D
Fiber supplementation
Hint:
See E for explanation
E
all of the above
Question 5 Explanation: 
Treatment includes bulking agents and increased fluids to avoid straining. Sitz baths will relieve acute pain. Topical nitroglycerine ointment, silver nitrate or gentian violet solution may help with healing.
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Brian Wallace PA-C Podcast: The Rectum, Hemorrhoids and Hernias (Prev Lesson)
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