Monday, August 3, 2015

Don’t ignore anal bleeding –Expert

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In this interview, a lecturer at the University of Lagos and honorary consultant General Surgeon, Lagos University Teaching Hospital, Dr. Abdulrazzaq Lawal, discusses anal fissure and its treatment

What is an anal fissure?
An anal fissure is a wound in the anal canal. Technically speaking, it can be described as a tear distal to the dentate line in the anal canal. Pain during the passage of a hard bowel movement, and sharp pain that continues afterward are the most common symptoms of an anal fissure. Sitting can be quite painful with an anal fissure.

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A few drops of blood may be seen in the toilet bowel or when wiping. In an infant, there may be blood in the diaper. The sphincter muscles that surround the anus and help prevent stool leakage may go into spasm and cause longer lasting pain with an anal fissure.
The anus allows bowel continence, which is voluntary control over the passage of bowel faeces. Waste is massaged down the length of the large intestine by waves of muscular contractions (peristalsis). Once the excess water is removed, the waste is temporarily stored in the rectum. The rectum joins to the anus, which is a short tube containing a muscular ring (sphincter) that can be opened at will to allow the expulsion of faeces The membranous lining of the anus is called the anal mucosa. An anal fissure is a tear in the anal mucosa.

How does it occur?
There is a consensus that it is caused by injury to the anal canal. This injury can be caused by several factors including but not limited to passage of hard stools.
What are the symptoms?
The chief symptom of anal fissure is excruciating pain in the anal canal. This usually occurs during or immediately after defecating. This then causes the person to develop a morbid fear of going to the toilet. Sometimes, there may be blood passed with the stool or after the stool. However, it is important to inform our people that any form of bleeding through the anus must be checked by a qualified physician. This is because it can be a symptom of more sinister problems such as cancer. It is therefore not appropriate for anyone to assume, based on my report, that bleeding can be caused by fissure and therefore one has fissure because one is bleeding during defecation.
For unknown reasons, anal fissures are common during infancy. They occur in babies during the first year of life. Older adults are also prone to anal fissures due to decreased blood flow in the anorectal area. During and after childbirth, women are at risk because of the straining during delivery.
If one has an inflammatory bowel disease, such as Crohn’s disease, one has a higher risk of developing anal fissure. This is because the inflammation in the intestinal lining makes the tissue more prone to tearing. One is at risk of developing anal fissure if one experiences frequent constipation where one has to strain to pass stools.

How is it diagnosed?
Diagnosis is usually through discussions with the patient– termed history taking – and examination of the anus. There is usually no need to insert the finger or any instrument into the anus because it can be excruciatingly painful. Just parting the anus will usually show the tear. The position of the tear may also be identified by the presence of anal tags. Skin thickens at the edge of the anus.

How is it treated?
Treatment is mainly dependent on the patient. This is because simple measures such as change in diet, drinking a lot of water and eating a lot of fruits and high fibre diets –containing a lot of vegetables may sometimes be all that is required to soften the stool and give the mucosa of the anus time to heal. If these do not suffice, Sitz baths may be ordered. This is not like the usual bath where you wash your body. No, it refers to a special situation where the anus is douched in warm salty water containing some chemicals.
If however these do not work, then surgery may be indicated. This ranges from simple procedures such as just stretching the anus to more complex procedures where tissue from nearby such as the buttocks, may need to be taken to cover the wound for the wound will heal. The major aim of the treatment is either to give the body time to heal the wound, or stop further insults during the healing process or cover the wound with new tissues to heal the wound.

Tell us about the surgery for anal fissures.
Severe anal fissures need to be surgically corrected. The fissure and associated scar tissue is removed. Sometimes, a thin slice of muscle from the anal sphincter is also removed, as this helps the wound to better heal. (Cutting and suturing this muscle doesn’t interfere with the patient’s sphincter control.) The operation, called a lateral internal sphincterotomy, can be performed under local anaesthetic.

What happens if anal fissure is not treated?
That’s the interesting thing about anal fissures. If untreated, the patient is afraid of going to the toilet and the stool accumulates and becomes harder and when eventually they are forced to go to toilet, they further aggravate the condition thereby setting up a vicious circle. Eventually, with repeated scarring and healing, it may even lead to narrowing of the anus and the vicious circle can only be broken by surgery at this stage of the disease.

What medicine is used for anal fissures?
Several medicines have been tried including pain killers applied to the anus or swallowed. However none of them is as good as dietary modifications added to sitz bath. The best treatment with highest success rate is usually surgery. But the patient has to allow healing by modifying the diet and doing sitz bath before surgery becomes indicated.

What are prognosis and complications?
Prognosis is usually very good and depends on the cause. I would also want to mention that this condition may also be present in patients suffering from a rare disease known as Crohn’s Disease. Anal fissures are also common in patients suffering from HIV-AIDS. In these two conditions, the prognosis is not as good as in patients without any underlying disease. In patients without any underlying disease, the prognosis is usually excellent. The surgical treatment sometimes has a minimal risk of incontinence; thus, surgery should only be performed by well trained persons. Incontinence means the patient will exchange perpetual pain during defecation for inability to control defecation and may sometimes defecate on the body and this may be embarrassing to the patient in the society.

How can one prevent constipation?
Constipation can be prevented by drinking a lot of water and eating high fibre diet. People should also not unnecessarily delay going to the toilet as this may also lead to constipation.

Are there natural treatments for anal fissures symptoms?
I am not an expert in that field, however, there are claims and counterclaims but none of them have been put through the rigours of scientific evaluation.

Culled - Punch

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