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.