China Association of Chinese medicine anorectal BranchDepartment of colorectal surgery, Chinese Academy of Medical SciencesChina Association
China Association of Chinese medicine anorectal Branch
Department of colorectal surgery, Chinese Academy of Medical Sciences
China Association of traditional Chinese medicine and Western Medicine
China Association of Chinese medicine anorectal Branch, Chinese Medical Association of colorectal and anal surgery surgery society study group, Chinese Association of integrative medicine in the diagnosis of Coloproctological Specialized Committee, standard reference "anal fissure (2002, draft)" on the basis of the combination of evidence-based medical research results and expert opinions, formulate the "Guide" of clinical diagnosis and treatment of anal fissure for clinicians, with reference to the implementation of Chinese.
Anal fissure is formed under the dentate line anal skin longitudinal dehiscence after ischemic ulcers occurred in young adults. At present, the pathogenesis is not clear, mainly related to internal sphincter spasm, post injury infection and so on.
First, clinical manifestation
1 symptoms: defecation time and after a sharp cyclical sharp pain, a small amount of blood in the stool, color red, accompanied by constipation, anal secretions and pruritus.
2, signs: good hair at the posterior or anterior anal ulcer, chronic anal fissure with sentinel hemorrhoid, anal papilla, anal sinusitis, sneak fistula.
(1) phase I: superficial longitudinal anal fissure anal skin ulcer, wound edge neat, basal fresh, red, tenderness.
(2) phase II: from the history of recurrent anal fissure. The wound margin is irregular, and the elasticity is poor, and the ulcer base is often gray and white.
(3) phase III anal fissure: Anal tightening, the ulcer base showed fibrosis, accompanied by hypertrophy of anal papilla, ulcer near sentinel hemorrhoids, fistula formation or stealth.
Two, differential diagnosis
For chapped, inflammatory bowel disease and skin of anus, anal ulcer anal squamous cell carcinoma, syphilis, tuberculosis ulcer ulcer identification.
1, hot colon dry
Anus pain, even red face sweat, blood in the stool, blood red, drop out, or toilet paper with blood; red tongue, yellow dry, and pulse number of strokes.
2, damp heat bets
Not very dry stool, abdominal discomfort, and defecation when unhappy, anal bulge, have mucous blood, sometimes accompanied by anus eczema, anal fissure often has a little pus, red tongue, yellow greasy moss, pulse moisten number.
3, Yin (blood) deficiency intestinal dryness syndrome
Dry stool, to solve it, anal pain, bleeding, pain, such as acupuncture, upset and dry mouth, want to drink more, red tongue, less moss, pulse breakdown.
Principle of treatment
Lift the sphincter spasm and pain, soften the excrement, terminate the vicious spiral, promote wound healing; complications associated with synchronous lifting; healing of durable, non surgical treatment of anal fissure by surgical therapy can be invalid.
Two, non-surgical treatment
(a) TCM Treatment
1, type of syndrome
(1) syndrome of heat and dryness of colon
Add and subtract the New Yellow Dragon Decoction
Commonly used drugs: Rhubarb and mirabilite (9g after) 3G, 15g, 15g, Radix Scrophulariae Radix 15g, 12g, 12g fried fried Burnet Huaihua, Fructus 12g, licorice 8g.
2, damp heat card
Example: four wonderful pill addition and subtraction
Commonly used drugs: 12g, 12g, cypress, Atractylodes, Achyranthes 12g coix seed 12g.
3, Yin (blood) deficiency intestinal dryness syndrome
Cure: Yin Qingrerunchang
Example: Zhibaidihuang pill and Zengyetang
Commonly used drugs: 6G, 6G, Anemarrhena phellodendron, Coptis chinensis, Radix Scrophulariae 6G 6G from 3G, 6G, 6G, woody peony Maren 6G, not 6G, the treatment of dairy raw licorice 6g.
(two) external treatment
1, sitz bath of Chinese Medicine
Available Zhitong rushen decoction, heat dampness, promoting blood circulation and relieving pain. Angelica 10g, 10g, 10g, peachseed Huangbai areca 10g, 10g, 10g, gleditschia agent 10g, Alisma Rhizoma Atractylodis wind 10g, Qin 6G, rhubarb 6G (after).
2, topical drugs
0.2%, such as nitroglycerin ointment Mayinglong hemorrhoids ointment, a few patients using nitroglycerin ointment after the headache disappeared after stopping drug.
3, anal expansion method
Use toilet paper or mechanical dilatation of anal canal, with one hand refers to the degree of 3. Some patients with skin laceration, local hematoma and mild anal incontinence. With the method of anal sphincter function was significantly reduced in patients.
Currently there is the use of botulinum toxin A injection, China has not yet universal.
Three, surgical treatment
(I) operation mode
1, partial internal sphincterotomy
Mainly applicable to the period of anal fissure. Include：
(1) lateral internal sphincter amputation
Lateral internal sphincter amputation surgery is the most frequently selected in clinical, it can effectively reduce the complications and the recurrence rate of surgery, but still had bleeding, pain, infection, fistula and stricture of anus, anal incontinence and other complications. Including open and closed two.
(2) partial internal sphincterotomy
Directly through the fissure incision of internal sphincter incision of internal sphincter, sometimes lower, such as inflammation, hypertrophy of anal fistula or external hemorrhoids resection and nipple. Open incision, slow healing, the occasional "lock hole" deformity.
2, mobile flap plasty
Suitable for the treatment of anal skin has a larger defect and has obvious stenosis and anal fissure and internal sphincterotomy after prone to anal incontinence patients, such as the elderly, women, can also be used for anal pressure is not high in patients.
3, anal fissure and Seton
Suitable for anal fissure with stealth fistula. In order to avoid the postoperative pain, local injection, included analgesics. Suitable for outpatient treatment.
(two) postoperative complications
1, anal incontinence
Surgical treatment of patients with obstetric injury history need to be cautious. Anal incontinence due to postoperative deformity of "iron hole".
2, wound healing or recurrence
If the bath, softening the stool and other conservative treatment still cannot heal, again for lateral internal sphincter amputation.