© Borgis - Postępy Nauk Medycznych 8/2013, s. 552-556
*Agnieszka Kucharczyk, Małgorzata Kołodziejczak
Szczelina odbytu – najnowsze poglądy i kontrowersje na temat diagnostyki i leczenia
Anal fissure – new concepts and controversies in the diagnosis and treatment
Department of General Surgery, Proctology Unit, Solec Hospital, Warsaw
Head of Department: Jacek Bierca, MD, PhD
Head of Unit: Małgorzata Kołodziejczak, MD, PhD
Szczelina odbytu jest jedną z najczęściej występujących łagodnych chorób odbytu i jest chorobą powszechną. Czynnikiem inicjującym powstanie szczeliny odbytu jest uraz mechaniczny twardymi masami kałowymi, zaś współistniejące zmniejszone ukrwienie tkanek wokół szczeliny oraz zaburzenia relaksacji mięśnia zwieracza wewnętrznego prowadzą do braku gojenia po urazie. Wstępne leczenie szczelin odbytu jest leczeniem zachowawczym. Obok leczenia klasycznego – ciepłych nasiadówek, maści z nitrogliceryną lub blokerami kanałów wapniowych – w ostatnich latach pojawiły się doniesienia o stosowaniu nowych leków w celu uzyskania farmakologicznej sfinkterotomii, takich jak bethanechol – agonista receptorów muskarynowych, oraz sildenafil – inhibitor fosfodiesterazy typu 5, o łagodnym działaniu rozkurczającym na mięśnie gładkie naczyń krwionośnych. Autorki opisują dobry efekt terapeutyczny przy zastosowaniu miejscowym 7% maści z sukralfatu, soli glinowej siarczanu sacharozy, stosowanej w leczeniu owrzodzeń żołądka. Kwalifikacje do leczenia operacyjnego szczeliny odbytu uległy znacznemu zawężeniu. Złotym standardem jest boczna sfinkterotomia. W artykule dokonano przeglądu piśmiennictwa na temat różnych modyfikacji bocznej sfinkterotomii (m.in. przedstawiono segmentalną boczną sfinkterotomię wewnętrzną). Autorki uważają, że nowe techniki operacyjne wymagają zachowania należytej ostrożności, ich rzeczywistą skuteczność oraz ewentualne powikłania czynnościowe w postaci osłabienia kontynencji można będzie ocenić dopiero po kilkuletniej obserwacji.
Anal fissure is one of the most common as well as widespread benign diseases of the anus. Fissure development is initiated by a mechanical injury that is induced by hard faecal mass and remains unhealed if the blood flow in the tissue surrounding the fissure is reduced and the relaxation of the internal anal sphincter is impaired. Conservative treatment is administered as the initial treatment for anal fissures. In recent years, apart form the traditional treatment options, such as warm-water bath, ointments with nitro-glycerine or calcium-channel blockers, there have been reports of using new drugs for pharmacological sphincterotomy. They include bethanechol, which is a muscarinic receptor agonist, as well as sildenafil – a phosphodiesterase type 5 inhibitor which is a mild dilator of blood vessel smooth muscles. The authors describe a good therapeutic effect achieved with topical treatment with 7% sucralfate (sucrose sulphate-aluminium complex) ointment that is used for the treatment of peptic ulcers. Qualifications for the surgical treatment of anal fissure have been made significantly more stringent. Lateral sphincterotomy is the gold standard. The article presents a review of literature on various modifications of lateral sphincterotomy (among other things, segmental internal lateral sphincterotomy was presented). The authors believe that the new operative techniques require due caution and their actual efficacy and possible functional complications such as impaired continence, may be assessed only after a few years of follow-up.
Anal fissure is one of the most common benign anal diseases, and is a common disease. Approximately 10-15% of patients presenting to outpatient surgery complain of symptoms associated with the onset of anal fissure (1). The fissure usually refers to patients between 30th and 50th years of age. The most common location is the area of dorsal commissure. Anal fissure located on the sidewall may be a symptom of other diseases, such as neoplasia, leukemia, Bowen’s disease and Paget’s disease, tuberculosis, syphilis, AIDS, or inflammatory bowel disease.
Theories on the pathogenesis of anal fissure in recent years have undergone great changes.
Currently, in the literature, authors emphasize that the factor that initiates the formation of an anal fissure is an injury – often hard fecal masses (2), but among other factors diarrhea may also be included (3), inflammation and scar tissue in the anal canal, the introduction of a foreign body – also during endoscopy. Co-reduced blood supply to the tissues around the fissure, and disorders of the internal sphincter muscle relaxation leads to a lack of healing after injury.
In studies of blood flow around the anodermal area performed using the Doppler method it has been shown that it is reduced within the dorsal commissure (4). In patients with anal fissure it was found that blood flow in the area of the fissure is significantly lower compared to the control group.
It was also found that in patients with anal fissure Gowers’ rectoanal inhibitory reflex (RAIR) is abnormal. There is no relaxation of the internal sphincter muscle, there is a paradoxical contractile response of sphincter during pressure, abnormal visceral sensation in the rectal ampulla (5).
According to Lim et al. additional predispose to the formation of the fissure may be increased by the production of endothelin-1 – epidermal blood vessels shrinkage enhancing factor. Increases in the levels of endothelin-1 in blood were found in patients with chronic anal fissure compared with healthy subjects and patients with third or fourth-degree hemorrhoidal disease (6).
Recognition and diagnosis
The diagnosis of anal fissure is easy. In interviews, patients give symptoms such as bleeding and severe pain associated with defecation or appearing after defecation and persisting for up to several hours (7).
Other symptoms may include a tendency to constipation, the presence of secretions, maceration changes of the anal area (8). Some patients have problems holding the gas and liquid stool. In the physical examination it is usually sufficient to spread the buttocks, which allows for the visualization of the fissure.
In patients with acute anal fissure in an examination through the anus generally increased tension of the internal sphincter muscle is observed and the introduction of a finger into the anus may worsen pain in the rectum. Nevertheless, per rectal examination should be performed to rule out other diseases that may also cause pain. Skillfully performed per rectal examination should not be too painful for the patient and the mechanical stretching of the anal sphincter muscle causes its knee-jerk relaxation and pain relief (9). In chronic anal fissure pain is usually not so strongly expressed, or does not exist at all. A little more tense sphincter can persist. After stretching the buttocks hard edges of the ulceration scar are visible, and at the bottom of the fissure the internal sphincter muscle fibers. Outside oversized fold of skin is visible. In the anal canal in the area of the distal fracture increased wart dentate line is reflected. In some cases of chronic fissure, low intersphincteric fistula can be formed, reflected in the form of beads.
A new element in the diagnosis of fissure is the use of endosonography becoming more and more widespread.
Reports on the performance of ultrasonographic transrectal examinations in patients with anal fissure began to appear in the literature in the early 90’s. Chronically elevated tension of the internal sphincter muscle causes its thickening in 64 to nearly 70% of patients (10, 11). Preoperative diagnostic ultrasound is an accurate assessment of the state of the sphincter in patients and the exclusion of coexistence of other pathology of the anal canal. Authors point out that the sensitivity of endosonografic examination in the assessment of the anal sphincter is between 95-100% and the specificity 75-85% (12). This examination may therefore have an impact on the choice of surgical technique, especially in the context of the implementation of a more or less total sphincterotomy.
Gauge examinations also constitute the extension of diagnosis in recent years. In most publications authors estimate patient continence after fissure treatment for comparison of different treatments – both conservative and operational ones (10, 11, 13).
Initial treatment of anal fissure is a conservative treatment.
The conservative treatment of anal fissures uses warm sitz baths, ointments with nitroglycerin or calcium channel blockers, methods with a long-lasting strong position (14). Including such substances such as salbutamol into treatment – the agonist of beta-2 receptors causes smooth muscle relaxation, L-arginine – which is the physiological precursor of nitric oxide – and 1% of clove oil have been the subject of research and publications in the 90’s.
In recent years, there have been reports on the use of new drugs for pharmacological sphincterotomy. These include the Bethanechol – muscarinic receptor agonist. In a study of a group of 15 patients a dose--dependent reduction of the pressure in the anal canal was achieved while achieving the maximum pressure reduction by 24% when using 0.1% Bethanechol ointment. 60% of patients were cured in the course of 8 weeks of treatment. There were no side effects (15).
Promising results have been obtained with the use of sildenafil. It is an inhibitor of phosphodiesterase type 5, with a mild relaxant effect on vascular smooth muscles. Registered and used in the treatment of primary pulmonary hypertension and potency disorders. Results published in individual reports need confirmation in a larger group of patients (16).
Povidone iodine is used to treat ulcers, infectious diseases of the skin and mucous membranes, burns, washing traumatic wounds. It has bactericidal antifungal and antiviral activity. Durai et al. used to treat anal fissure with 10% povidone iodine solution, applied twice a day for 5 days. During a year of observation, there was no recurrence of the fissure (17).
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