ANAL FISSURE/FISSURE-IN-ANO - Causes, prevention and treatment

Anal fissure or Fissure-in-ano is a kind of longitudinal cut (linear ulcer) at the anal canal  outer anterior and posterior margins (skin-lined part) which is formed when a person suffering from constipation passes hard stool with strain. It is extremely painful ano-rectal condition which lead sufferer into stress and anxiety. The person is so much distressed that he/she develops fear for passing stool. This tendency however adds to his problem as it further aggravates the problem of constipation.

Anal fissure commonly occur at midline posteriorly but sometimes seen at midline anteriorly and rarely seen at anywhere in the anal circumference.

The ulcer of anal fissure doesn't heal up easily because;

1. The anal canal always full of microorganisms i.e. it is always lodged with infection.
2. The passage of hard stool during the act of defaecation prevents it from healing easily.

In acute stage the fissure is extremely painful and may bleed frequently but if ignored for a long time for more than 7-8 months, it gets partially healed up and a skin growth known as sentinel tag or sentinel pile surrounds it. This sentinel tag further hinder the complete healing of the underlying fissure.

Who suffer more from Anal fissure the causative factors?

• People who have a habit of eating junk food and fast food with less dietery fibres.
• People who drink less fluids and water.
• People who do not exercise or walk and have sedentary lifestyle.
• Women during pregnency generally develop constipation and thus anal fissure is seen more in women than men.

How fissure can be prevented?

The primary cause of anal fissures is constipation. So, one has to develop habits by which constipation can be prevented. A few measures can be;

1. Taking adequate dietary fibers. Eat more vegetables, fruits and salad.
2. Drink plenty of water and fluids but avoid much coffee and tea.
3. Avoid straining during defaecation.
4. Avoid excessive chillies and spices in food items.
5. Avoid much of non-veg. food. Try to be vegetarian.
6. Use of buttermilk (Lassi without butter) with a pinch of cumin powder and black salt keeps the digestion correct.

What is the treatment? 

In acute condition, medicines to relieve constipation along with Ayurvedic healing oils for local application, are prescribed. Dilation using anal dilators of appropriate diameters or using index finger is done along with ayurvedic healing oils. However if the condition becomes chronic and sentinel tag has been formed, surgical intervention is necessary. 

In Ayurveda the sentinal tag is cut by using a specialized medicated alkaline thread ligation technique, known as Kshara-sutra ligation which offers a better way to treat chronic fissure-in-ano than conventional surgery. Kshara sutra method is least invasive para surgical procedure for cutting benign tissues like sentinel tag, piles masses, warts, condyloma etc. In this technique a highly specialized medicated thread is ligated tightly around the sentinel tag, which strangulate the tissue and cause necrosis thus the tag fall off in 3 to 5 days. The underlying fissure heals up in next 5-15 days. Ayurvedic medicines for constipation and Ayurvedic healing promotion oils like Jatyadi oil or panchguna oil etc.along with Finger dilation of anal canal (Ganesh Kriya) are used till the fissure gets healed completely. 

Sitz bath :- In acute as well as chronic cases of fissure in ano, Sitz bath with lukewarm triphala or panchwalkal kwath is quite helpful in relieving the pain. Patient should use a plastic tub of appropriate diameter and fill it with lukewarm panchwalkal/triphala kwath or simply tap water with some some antiseptic solution and should sit in such a way that his anus and buttocks get submerged inside the warm medicated water. It greatly help in reliving the pain in ano-rectal diseases and gives a soothing effect.Sitz bath is advised in all patients suffering from fissures, piles or fistula in ano and also it is an important part of post operative treatment in ano-rectal cases.

PILES/ HEMORRHOIDS : Kshara-sutra treatment

The disease piles is as old as the history of mankind. A lot of people suffer from it and many of them hide the disease and reach to the doctor when the disease become chronic and only surgical option is left then usually.

Hemorrhoids are defined as varicose condition of haemorrhoidal plexus. In modern era, Hippocrates, The Father of Modern Medicine (450 B.C.) has also described the method of diagnosing ano-rectal disorders. Later on, in the present era Turell (1960) told that about 70% of human beings suffer from haemorrhoids and 40% of them need surgery. About 10% cases remain undiagnosed and do not visit doctor. Golligher (1967) expressed that the incidence of hemorrhoids increases with the age and at least 50% of the people over the age of 50 have some degree of hemorrhoids. Ferguson (1973) reported that 100% of the population has hemorrhoid but 50% may be symptomatic. Men seem to be affected more as compared to women. It is very common above the age of 30 years.

A case of 3rd degree internal hemorrhoids.

Causes 

Primary causes

1.                  Heriditary

2.                  Constipation

3.                  Diarrhea and dysentery

4.                  Faulty habits of defecation

5.                  Dietary habits

6.                  Anatomical factors 
Secondary causes

1.                  Portal obstruction

2.                  Carcinoma of rectum

3.                  Abdominal tumors

4.                  Pregnancy

CLASSIFICATION:

A. In relation to site of origin

1.                  Internal hemorrhoids

2.                  External hemorrhoids

3.                  Interno-external hemorrhoids

B. In relation to pathological anatomy

1.                  Primary hemorrhoids

2.                  Secondary hemorrhoids

C. In relation to pathophysiologically

1.                  Mucosal

2.                  Vascular

D. In relation to facilitate the line of management

1.                  1^st degree hemorrhoids

2.                  2^nd degree hemorrhoids

3.                  3^rd degree hemorrhoids

4.                  4^th degree hemorrhoids

CLINICAL FEATURES:

1.          Bleeding during defaecation

2.          Prolapse of mass during defaecation

3.          Discharge

4.          Anal irritation

5.          Pain

6.          Anaemia (If bleeding is persistent and severe)

COMPLICATIONS:

1. Hemorrhage
2. Strangulation
3. Thrombosis
4. Ulceration
5. Gangrene
6. Suppuration
7. Fibrosis
8. Pylophlebities

DIFFERENTIONAL DIAGNOSIS:

            It should be differentiated from;

1.                  Partial prolapse of rectum

2.                  Rectal polyp

3.                  Carcinoma of anal canal

4.                  Multiple small ulcers in the rectum

5.                  Condyloma lata and accuminatum

6.                  Sentinel tag

In Modern science the following types of treatments are available to treat the disease;

1.       Medical treatment

2.       Sclerotherapy

3.       Barron Band Ligation

4.       Lord’s manual dilation

5.       Cryosurgery

6.       Pedicle ligation
7.       Haemorrhoidectomy

                  8. Infrared coagulation 
ayurvedic treatment of haemorrhoids: 
  
Application of Kshar sutra in Arshas (Haemorrhoids)

Pre Kshar sutra measures:

a.      The patient should be admitted in the hospital a day before operation.

b.      Soap water enema should be administerd after admission.

c.       Shave and part preparation done.

d.      Keep the patient fasting at least for 8 hours

e.      Consent of the patient in written

f.        Proctoclysis eneme 2 hours before the procedure

g.      Inj. Xylocaine sensitivity test

h.      Inj. Tetenus toxoid 1 Amp. IM stat.

EQUIPMENTS AND OTHER REQUIREMENTS

Proctoscope	Pile holding foreceps
Artery foreceps both Staight & curved	Sponge holding foreceps
Surgical gloves assorted size and pair	Scissiors
Needle holder	Round body curved needles
Towel clips	Syringes
Swabs	Linens
Kshar sutra

POSITION: Maximum number of patients has lithotomy position for this procedure.

Kshar sutra ligation procedure:

• The patient is made to lie on the operation table in Lithotomy position.

• The perianal area is cleaned with Savlon and spirit followed by Betadine painting.

• The outer area is covered with sterile cloth, leaving the anal area open.

• Proctoscopy is done and the positions of various pile masses are assessed.

• The pile mass is protruded outside by asking the patient to strain out.

• Hold the pile mass with pile holding foreceps.

• Then Inj. 2% Xylocaine is infilterated around the root of pile masses.

• The protrued pile mass is held with pile holding foreceps. Slight pull is exerted over the pile mass, so that the base of pile mass is clearly demarcated alongwith the blood vessel.

• The pile mass is transfixed with curved cutting needle with the help of needle holder and it is followed by kshar sutra ligation.

• The same procedure is performed to ligate other haemorrhoids if present.

• The ligated haemorrhoids are replaced inside the anal canal and the kshar sutra is allowed to suspend out.

•  10 ml. of jatyadi oil is pushed inside the rectum and sterilized gauze is applied on the anus.

•  T-bandage is tied to keep the dressing in proper position.

•  Thereafter the patient is shifted to the ward.

Post Kshara-sutra ligation management:

1.       Nil orally for 4 hours

2.       Give liquid diet after that to avoid any type of inconvenience.

3.       Note pulse, temp., B.P. 6 hourly

4.       If operation is done under spinal anaesthesia, to avoid complication give head-low position to the position for 48 hours.

5.       Jatyadi oil P/R BD

6.       Hot sitz bath with panchvalkal kwath 8 hourly

7.       To avoid hard stool, give mild laxative to the patient

8.       If pain is excessive, urinary retention was occurred then go for the systemic treatment.

Mode of action of Kshara-sutra:

Kshar sutra by its chemical cauterization and mechanical strangulation of blood vessels, causes local gangrene of the pile mass and pile mass get removed within 5 to 7 days. No effort should me made to pull out the Kshar sutra or pile masses as it may cause pain and bleeding which is not desirable. The healing of the resulting wound takes a week’s time.

Post Kshara-sutra ligation complications:

1.        Retention of urine – It has been observed that within 8 to 10 hours after ligation, some of the patients complain of retention of urine which can be tackled by frequent sitz bath in lukewarm panchvalkala kwatha or simple warm water. Catheterization is seldom required.

2.        Local irritation – In some of the patients local i.e. perianal irritation is seen which needs frequent use of oil application and hot sitz bath etc.

3.        Abscess formation – In some of the patients (especially who was suffered from interno-external piles), abscess formation takes place which was managed with local application of Dashang lepa with Goghrita.

4.        Haemorrhage – Alarming type of haemorrhage is not a rule with Kshar sutra treatment. However in some of the cases slight oozing may be seen which need no special care except the usual routine line of management, viz. avoidance of hard stool and much straining during defecation.

Pathya-apathya:

From the very first day of Kshar sutra ligation light diet like Khichri is advised. Patient is also advised to take plenty of fluids, blend diet, green vegetables and seasonal fruits. Patient is further advised to avoid spicy and fried food and not to strain during defecation.

Finger dilation of anus/Ganesh kriya: From 3^rd week of Kshar sutra application or after the falling of pile mass, lubricated index finger with jatyadi oil is gently introduced inside the anal orifice and is gradually rotated clockwise and anti-clockwise for 2 to 3 minutes.

Patient is advised to carry out this practice of this procedure by himself by using the finger stall on right index finger after defecation in the squatting position daily for a period of 1 to 3 months. Such a practice is advised just to avoid any chance of post ligation narrowing of anal opening.