PANCE Blueprint GI and Nutrition (9%)

51-year-old with rectal bleeding and abdominal pain

Patient will present as → a 45-year-old man with severe rectal pain when he defecates, which lasts for several hours and subsides until the next bowel movement. He has been constipated for the past 6 months, and when he does have a bowel movement, the stool is covered with bright red blood. A sentinel pile is noted on the physical exam.

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

• Caused by: hard stool passage (constipation), hyperactive sphincter, disease process (e.g., Crohn’s disease)
• The fissure may cause internal sphincter spasm, decreasing blood supply and perpetuating the fissure
• Presents with pain in the anus, painful (can be excruciating) bowel movement, rectal bleeding, blood on toilet tissue after bowel movement, sentinel tag, tear in the anal skin, extremely painful rectal exam, sentinel pile, hypertrophic papilla

An anal fissure is a small tear in the thin, moist tissue (mucosa) that lines the anus. 90% of fissures are formed along the posterior midline of anal canal.

Diagnosis is made by history and visual inspection with anoscopy

• A sentinel pile (thickened mucosa) is found below the fissure
• Unless findings suggest a specific cause or the appearance and/or location is unusual, further studies are not required

For patients with a typical anal fissure (ie, a single posterior or anterior fissure with no evidence of Crohn's disease), treatment consists of a combination of supportive measures (fiber, sitz bath, topical analgesic) and one of the topical vasodilators (nifedipine or nitroglycerin) for one month.

Treatment acronym WASH

• W arm sitz baths: which can relax the anal sphincter and improve blood flow to the anal mucosa, are recommended for patients with anal fissures
  • During a sitz bath, the anus is immersed in warm water for approximately 10 to 15 minutes two to three times daily or showers immediately after every bowel movement
• A nalgesics: 2% lidocaine jelly
  • Topical vasodilator:
    • topical 0.4% nitroglycerin rectal ointment (Rectiv) twice daily
    • topical 0.2 to 0.3% nifedipine ointment two to four times daily in patients who have access to a compounding pharmacy
• S tool softeners (Colace)
• H igh Fiber: the recommended dietary fiber intake is between 20 and 35 grams per day
  • Patients who continue to have difficulty with hard bowel movements despite increasing dietary fiber intake may use fiber supplements, such as psyllium seed (Metamucil), methylcellulose (Citrucel), wheat dextrin (Benefiber), and calcium polycarbophil (Fibercon)

Second-line therapy

• Topical Ca channel blocker (Diltiazem 2% rectal gel is applied three times daily for eight weeks), or botulinum toxin type A injection