Definition:

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FISSURE IN ANO

Definition It is a common disease of anus and
a painful condition which makes the patient often
anxious and embraced. The word Fissure means
crack. It is longitudinal crack in the long axis
of the lower anal canal. In other words we can
just say that it is true ulcer of the skin of the
wall of the anal canal. As per the Ayurved,
Fissure is compared with a similar anal
condition known as Parikartika which is nothing
but an ulcer or Aagantuj vran in the anal
canal which is associated with severe burning
cutting/ tearing pain at anal region. Sushrut,
Charak Vagbhatt mentioned Parikartika as the
complication of other diseases or procedures
whereas, Kashyap has described this as a
independent disease.
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AETIOLOGY

• Poor muscular support of the posterior
• wall of the anal canal
• Acute angulations of the posterior rectalwall
  with the posterior wall of the anal canal
• Trauma when a scybalous mass is being expelled
• Anal infection any infection within the anal
  canal( like followed by diarrhea etc. or due to
  poor hygienic conditions) is followed by
  inflammation which may turn into ulcer
• Constipation a forceful daefication due
• to hard stool can cause over stretching
• of the anal mucosa resulting in ulcer

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Predisposing factor according to Ayurved

• Primary Most of the factors are similar to that
  of Piles like,
• - Unsalutary food habits
• - No fixed time for meal
• - Having frequent meal without
  considering the digestion of previous meal
  (Adhya ashan)
• - Having more of unnatural
  food stuffs like
• junk food,fast food, bakery products.
• - Suppression of urge of
  daefication causing Constipation
• - Night time awakening day
  time sleep
• - Excessive traveling
• - Overdose of NSAIDS,
  Antibiotics,
• Steroids, Antacids other
• Ushna-Tikshna medicines which
• disturbs the Agni.

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• Secondary due to upadrav or complication of
  other conditions can cause Parikartika
  like,
• - Jwar ( as in enteric fever)
• - Vataj Atisaar ( frequent loose motions
  causing inflammation in the anal canal)
  
• - Garbhini ( pregnancy or during delivery
  tremendous pressure on the anal canal
  causing ulcer)
• - Basti netra vyapad ( trauma due to tip of
  enema instument which can be avoided by
  using rubber catheters )
• - Vaman, Virechan vyapad ( over emisis or
  purgation i.e. Atiyog can cause ulcer)

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CLINICAL FEATURES

• Pain at anal region while after daefication,
  which subsequently continues as a burning
  discomfort for several hours.
• Sharp, cutting or tearing pain with act of
  daefication
• Severity of pain frightens the patient to
  daeficate
• Slight bleeding- usually stools are streaked with
  the
• blood
• Swelling and Pruritis Patient with a large
• sentinel tag may complain of painful external
  swelling with or without Pruritis
• Age and Sex More common in women occurs
  during middle edge. It is uncommon in aged
  because of musculature atone.
• Location Overall 90 situated at midline
  posterior i.e. at 6 o clock. Anterior fissure (
  12 O clock ) is common in females, whereas
  commonest site in male is 6 O clock.

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• Why Pain is more in Fissure ?
• Pain is more because during daefication, the anal
  fissures are stretched the margins of the anal
  ulcer are separated.
• The anal skin has somatic sensory nerve supply
  which is very sensitive causes sphincter spasm,
  leading to painful contraction. Here, one thing
  should be made clear
• that Spasm of the sphincter muscles
• results in pain, whereas the fatigue
• results in relief from pain. The attention
• of the patient is usually centered in his
• pain to the extent that he fails to mention
• the bleeding.

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Symptoms- According to Ayurved

• - Burning, cutting tearing pain at anal
  region
• - Abdominal discomfort mainly due to Meteorism
  (Anil sang)
• - Fullness of abdomen associated with
  dislike towards food
• - Indigestion Constipation
• - Burning pain at anal region extending up
  to Umbilical area, bladder, genitals entire
  waist area while after passing stool.
• - All the prodromal clinical features
• of Piles are also present.
• - If not treated properly, then it can lead
• to Piles, Fistula Abscess.

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TYPES OF FISSURE

• Two types of Fissure are seen
• 1. Acute Fissure
• - Sharp, cutting or tearing pain with act
• of daefication
• - It is deep tear through the skin of the anal
• margin extending into the anal canal.
• - There is little inflammatory induration
• or edema of its edges.
• - There is accompanying spam of the anal
  sphincter muscle
• 2.Chronic Fissure
• - It is comparatively less painful condition
• - Inflamed induarated margin may be present.
• - A base consisting of either scar tissue the
  lower border of the
• internal sphincter
• - the ulcer is cone shaped with skin tag i.e
  sentinel pile.
• - Infiltration of fibrosed tissue in the bed of
  ulcer.
• - Infection is common causing proctitis, abscess
  or cutaneous fistula.

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• Fissure is can be further divided into two types
  
• Primary Already discussed
• Secondary May be due to
• Granulomatous infection
• Chrons disease
• Syphilis
• Proctocoliitis
• Diabetes Mellitus
• As a compilation of Haemorriodectomy or
  fistulomtomy

If fissure is not treated it can cause - Absces
an fistula - Sentinal tag - Enlarged Papilae -
Anal contrictures Differntial diagnosis -
Anal abresion - Specific ulcerative lesion -
Veneral lesion - Tubercolosis - Carcinoma of
anus - Proctalgia Fugax( Cramp like pain at
irregular intervals more common with anxiety
patient)
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Treatment

• Paliative treatment
• Seitz bath
• Hot pack
• Anal heigene
• Application of Anesthetic ointments
• Laxatives
• To avoid constipation regularize bowel habit
• Olive oil enema
• Use anal dilators
• Injection of long acting of local anesthetics

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• Surgical Treatment
• 1. Anal dilatation
• Stretching of anal sphincters to achive fatigue
  of anal sphincters and to break the fibroses
  tissue embeded in ucler
• Limitations
• With in few hours of streching patient developes
  painful edema
• Some patients may develops temporary incontinance
  
• Contraindicated in II and III grade piles
• - In 16 patients this treatment did not prove
  successful

2. Excision of Anal fissure with or without
grafting -Excision of broad
traingle of skin of perinial region along with
the main lesion is done. 3. Sphinterectomy
Division of internal sphincter is done by
either, - Open posterior internal sphicterctomy
or - Lateral subcutaneous internal
sphicteractomy

• Complication
• -Anal incontinence ( temporary or permanent
  imapared control of fecaus is observed in 34
  patients )
• - Incontinence of flatus ( Observed in 9 of
  patients)

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Surgical Treatment
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Ayurvedic Management

• In acute conditions
• -Deepan and pachan chikitsa to improve digestion
  eg. Ajmodadi churna or hingvashtak churna,
  Dadimavaleha
• - Vata anuloman chikitsa eg. Avipatikar etc..
• - Laxatives or Mala sarak chikitsa
• eg Abhayaristha or Haritaki churna
• - Nagkeshar, lodhra etc.. To arrest bleeding
• - Daily takrapan i.e buttermilk to be advised
• - To have good quantity of milk in diet
• - Gudda ( jaggery ) Honey consumption
• Panchakarma
• - Cold water seitz bath in acute condition and
  hots seitz bath for chronic cases
• - Matra basti with yastimadh oil to promote
  healing as well as work as analgesic
• - Picchabasti of yastimadhu Black til Honey
  Ghrita
• - Local application of plain ghrita,
  shatadhauta ghrita, Raktachandan siddha ghrita
  or yastimadhu ghrita is equally effective

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Role of Kshar in fissure

• Role of kshar in fissure is very limited
• In north east part of the country, some Ayurvedic
  surgeon do use kshar for the purpose.
• They apply mild kshar or keep kshar varti (
  medicated thread) at the bed of chronic fissure.
  The mode of action may be
• This acts on the fibroses tissues and responsible
  for there lysis. Infact this fibrosed tissue
  plays a major role in delayed healing of ulcer.
• They may stop hyper granulation
• They promote healing

• How ever, after considering the severity of pain
  and burning rough ulcer ,the acceptance
• by patient for the above management is doubtful.
  
• This kind of treatment can be tried only in long
  standing chronic fissures.
• Agni mandya ( Low digestive power) which the
  causative factor in all ano-rectal diseases
• Can be treated with internal use of mild kshar in
  he form of shank vati etc..

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Request to patients

• Dont neglect any painful conditions related to
  anal region
• Dont hesitate to discuss the problem with your
  family physician regarding such problem.
• Most of the time acute anal fissure heals by
  itself with in 4-5 days
• If prognosis is not satisfactory then visit the
  nearby Ayurvedic Institute for further
  management.
• Dont go to the so called Traditional therapists
  (Madar-clinics, Bengali- healers or any other non
  registered practitioners ) because
• 1. They do not have any authentic qualification.
• 2. They do not posses any scientific skills or
  training from medical institue.
• 3. They are not aware of applied Anatomy
  patho-physiology of the disease so, there is a
  good chance of creating an iatrogenic track or
  damage or damage to the sphincter which leads to
  incontinence.

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• 4. They dont have the exact knowledge,
  management or significance of the underlying
  systemic disease like Kocks or Chrons disease,
  diabetes or HIV
• 5. If such patients of fissure visits so
  called specialist (quacks), they generally do the
  per-rectal digital dilatation of the anus with
  the help of jelly or apply some medicine in the
  anal canal which relieves the symptoms but if
  treatment dont work the fissure ultimately turns
  to abceses or fistula
• 6. It is reported that some of the quacks keep
  either a small flesh piece or Musta root (sooked
  in water for whole night) which resembles pile
  pedicle. After giving sedation or local
  anesthasia they pretend as if they have removed
  the pile mass
• 7. Most of the time i.e about 70 cases the
  painful defecation is due to fissure which heals
  itself but patient is told that they are
  suffering from piles and needs manual removal by
  traditional techniques but fact is that the
  symptoms relieved by the dilatation of anal
  sphincter.
• 8. . They do not follow the proper aseptic
  precaution or sterilization technique. Some of
  the quacks tie or cut the external sentinel tag
  under local anesthesia and convince that patient
  as if they are treated for piles
• 9.. They can not handle the complications.
• 10. They charge heavily to the patients.