Etiology and
Pathogenesis
It is caused by
constipation due to excessive heat and dryness in the
intestines, and by over-exertion on bowel movements. As Yi
Zong Jin Jian (The Golden Mirror of Medicine) says:"
Constipation, pathogenic fire and dryness are the cause of
the anal fissure." According to modern medicine and clinical
experience the etiology of the anal fissure has a certain
relation to the anorectal anatomy, but is chiefly related to
the local inflammation and mechanical injury, and both of
them are cause and result. The etiology will be discussed as
follows.
Factors of Anatomy
1. Small Elastic
Force of the Anus and Poor blood Circulation: Due to
distribution of the external sphincters, a triangle area is
formed. The superficial part of the anterior and posterior
anus has small elastic force and poor blood circulation. It
is held that the anal posterior internal sphincters do not
have enough support from the external sphincters, but on
both sides of the anus the external and internal sphincters
are tightly related to each other.
2. Heavy Pressure
on the Posterior Anus: the natural angle formed by the anal
canal (from the antero-lower to the postero-upper) and the
rectum increases the pressure on the posterior anus on bowel
movements.
The above two
factors illustrate the reason of the occurrence of the anal
fissure frequently at the front-back position, especially at
the back position.
Inflammation
Inflammation
decreases the tissue's elasticity and increases its
fragility. When mechanical injury is added, anal fissure
easily takes place.
Mechanical Injury
Mechanical injury
is the direct pathogenic factor and anal fissure is
considered an initial stage lesion. Chronic anal fissure may
develop on continuous inflammation, Constipation is the main
cause, but other causes, for example, injury by foreign
body, anal and rectal examination and operation exist. From
the above, we know that the chief cause is injury and
inflammation. Inflammation makes the tissue become brittle
and brittle tissues are easily ruptured. Mechanical injury
further make the brittle or healthy tissues be damaged by
inflammation, either of the factors, mechanical injury and
inflammation, being both a cause and effect. The affected
part cannot heal or relapse is frequently seen.
Other Factors
It is held that
anal fissure is related to conjunctival belt, or the
fibromembranous tissues, short or elasticity, between the
dentate line and the white line under the distortional skin.
Because of this condition, the anal canal is constantly in a
strained condition and the sphincters cannot easily relax.
Some people think
that the anal fissure is closely related to the internal
sphincters, and point out it usually takes place at the
internal sphincters. At the base of the edge of the fissure
in chronic anal fissure patients, the internal sphincter
fibrosis can be seen, but in the acute anal fissure patients
there is no such condition. On measurement of the pressure
and motility of the anus, it has been found that the anal
pressure in anal fissure patients forms caused y dysfunction
of the internal sphincters. It seems that the internal
sphincters are chronic over-exerting. But it is not clear
which is the primary or secondary result.
Special chapping or
ulcer due to tuberculosis is rarely seen clinically.
Clinical
Manifestations
Stage
Classification
It is necessary to
mention the clinical stage classification for better
treatment.
Anal fissure can be
divided into the acute and chronic Stages. The acute or
initial stage is manifested by inflammation, Swollen,
congestive edge of the fissure, and severe pain.
Inflammation gives rise to hyperplasia of the connective
tissues at the edge of the fissure. The chronic or late
stage called the old stage lesion is marked by relapse,
hyperplasia of the affected connective tissues, causing its
edge swollen and forming typical skin vegetation-a skin tag
at the end of the fissure, called formerly Shao Zhi, Shao
bing zhi.
Based on the
author's observation the acute attack does not necessarily
occur at the initial stage and the early fissure develops to
the chronic stage without a process of inflammation.
Therefore anal fissure can be grouped under the initial
stage, chronic stage and a special acute attack. The early
anal injury is produced by a mechanical injury. Some people
maintain that it is an injury of the anus due to rubbing,
which is different from the anal fissure. No matter what it
is called and how serious it is, it is exactly the anal
fissure, a precondition of inflammation. The early anal
fissure is easily to heal. The chronic stage has been
described as above. An acute attack may deteriorate the
condition, which occurs at any time between the initial
stage and chronic stage. The acute attack can be termed as
the inflammatory state of the anal fissure. It indicates
only the condition of the acute inflammation, not the time
of attack. Sometimes the anal fissure is divided into the
first second and third stages.
Symptoms and Signs
1. Main Symptoms
(1) Specific Pain:
Anal Fissure is manifested by severe pain, although it is a
local limited lesion. Therefore the main suffering is a
characteristic pain. Pain is present on bowel movements. A
radiation pain is felt, esp. on passing hard feces. Typical
cases are marked b moderate pain on bowel movements and
severe pain after that, with an interval between these
pains, forming a specific pain cycle. the severe pain after
an interval is brought about by sphincterismus, while the
moderate pain on bowel movements is the result of the direct
injury or irritation. Sphincterismus due to pain exerts
strong pressure on the fissure and makes the anus in a state
of constant tension.
(2) Hematochezia:
Anal pain and hematochezia of different extent occur
simultaneously on bowel movements in some patients. This
bleeding is different from that caused by the internal
hemorrhoids marked by the absence of pain. An examination
may tell the coexistence of hemorrhoid and fissure.
(3) Constipation:
Passing of dry stools may cause the anal fissure. Patients
are afraid of pain on bowel movements so that they dare not
to make bowel movements, which produces severe constipation,
resulting in a vicious circle, and habitual constipation
easily leads to anal fissure.
2. Local Signs
In general, the
early anal fissure looks red in color with orderly order and
has no skin vegetation. Prolonged anal fissure is dark red
in color and there is fibrous tissue hyperplasia at the edge
and base of the fissure. A skin tag produces outside the
fissure. The skin tag at the anterior, posterior and middle
positions is the typical mark of the chronic anal fissure.
Diagnosis and
Differential Diagnosis
It is easy to make
a diagnosis of the anal fissure, determined by the case
history and local physical signs. Patients often suffer from
constant constipation, pain, and it is easy to tell
hematochezia due to internal hemorrhoids from that due to
the anal fissure. On examination it is easy to find the
fissure occurring at the anterior or posterior anus only y
expanding the anus. Local signs should be under careful
consideration. For individual patients the anal fissure
cannot be discovered naturally, then anesthesia is followed
by examination.
Clinical Treatment
The treating
principle is to keep one's bowels open and heal the fissure.
The anal fissure is a mild condition with a severe pain. It
can be cured but recurs frequently. It is significant to
know this point, because it is helpful in differentiation of
syndromes. At the initial stage treatment is focused on
moistening the intestines and make free bowel movements,
kill pain and stop bleeding. Operation, in general, is
unnecessary. In protracted cases when there is a skin tag or
other complications, surgery is applied.
Internal Treatment
It is essential to
moisten the intestines and make free bowel movements, and
then give other therapies. So the internal treatment is
significant in cure and prevention of the anal fissure.
Clinically, it is most important to keep bowels open instead
of dealing only with the fissure itself. Comprehensive
measures can be adopted to keep bowels open. Here is a
detail account.
1. Proper Diet: It
is a main link. Intake of less food, lack of water and food
with less cellurose may cause constipation. It is advisable
to take more vegetables and fruits, water and beverages
helpful to keeping bowels open. The following is
recommended. The stuff suggested is carrot, radish, celery,
chive, spinach, Chinese cabbage, banana, pear, honey, sesame
oil, sweet potato, yam, water chestnut, raw or cooked
peanut, walnut, sesame, pine nut, white and black edible
fungus, pear juice, jujube juice, hawthorn juice and orange
juice.
Banana: It helps
bowel movements. At any time you can take it, or take it on
an empty stomach in the morning until free bowel movements
take place. For those who suffer from deficiency and cold in
the spleen and stomach, heat bananas with its skin in hot
water and then take them hot to avoid abdominal pain.
Pear: It helps
bowel movements, moistens the lung and stops coughing. Have
it mixed in hot water and take it. Good effect is seen when
it is taken on an empty stomach in the morning.
Sesame Oil: It
functions to eliminate heat and make free bowel movements.
Mix some in boiling water and take it on an empty stomach.
Sweet Potato, Yam:
Both function to make free bowel movements. Take cooked
sweet patato or yam as much as you like.
Waternut: It
functions to eliminate heat, and makes free bowel movements.
Take it raw or cooked as much as you like. The powder of
waternuts can be mixed in water or prepared into porridge
and take it on an empty stomach in the morning or several
times a day.
Peanut: Take raw or
cooked. The roasted or fried peanuts cannot make free bowel
movements.
Walnut: It
functions to strengthen the kidney, moisten the lung and
makes free bowel movements. Take it raw.
Sesame, Black
Sesame: They function to strengthen the liver and kidney,
and moisten the intestines. Take it raw or roast it and
grind it into powder, then take it with honey.
Pine Nut Kernel: It
contains rich Vitamin E, functioning to moisten the
intestine. appropriate amount is taken each time.
White, Black Edible
Fungus: It helps to make bowels open, replenish Yin and
moistens the lung. It can e taken as a single ingredient or
cooked.
Fruit Juice Helping
Bowel Movements: Appropriate amount of pear juice jujube
juice, hawthorn juice mixed with water can be taken several
times a day. Orange juice is good for regulation of qi flow,
free bowel movements and whetting appetite.
In the treatment of
constipation, in light of individual constitution, it is
advised to eat one kind of vegetable or fruit or several
kinds of vegetables and fruits a day. When the diet therapy
fails, take some purgatives, cessation of which follows if
bowel movements turn to normal. But the diet therapy should
go on.
2. Medication
It is advisable to
take drugs keeping bowels open. They include Tab
Phenolphthaleinum, Isaphenin, Tongbian Ling, Liqiid
Paraffin, Runchang Wan, Maren Wan, Maren Zipi Wan, Runchang
Pian, fried Semen Cassiae and Folium Cassiae tea.
Oleumricini has a strong action to relax the bowels, so it
is only used for constipation. Suppositories like glycerin
suppository, Daobian suppository and Kai Sai Lu can also
make free movements of the bowels. In addition, acupuncture,
moxibustion and massage are helpful to keeping bowels open.
In the morning
after getting up it is high tie for defecation because
peristalsis of the stomach and bowels is accelerating, which
may promote defecation. Although time of defecation varies
in different individuals, keeping the regular time is
important. For habitual constipation, give drugs according
to differentiation of syndromes. Timely treatment must be
given to severe cases of constipation.
Analgesics are
administered for severe pain of the anal fissure. Take
hemostats if there is much bleeding. No treatment is needed
for a little hemorrhage.