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How are anal fissures diagnosed and evaluated?
A careful history usually
suggests that an anal fissure is present, and gentle inspection of the anus can
confirm the presence of a fissure. If gentle eversion (pulling apart) the edges
of the anus by separating the buttocks does not reveal a fissure, a more
vigorous examination following the application of a topical anesthetic to the anus
and anal canal
may be necessary. A cotton-tipped swab may be inserted into the anus to gently localize the
source of the pain.
An acute anal fissure looks like a linear tear. A chronic
frequently is associated with a triad of findings that includes a tag of skin at
the edge of the anus (sentinel pile), thickened edges of the fissure with muscle
fibers of the internal sphincter visible at the base of the fissure, and an
enlarged anal papilla at the upper end of the fissure in the anal canal.
If rectal bleeding is present, an
endoscopic evaluation using a rigid or flexible viewing tube is necessary to exclude
the possibility of a more serious disease of the anus and rectum. A
examines only the distal part of the colon may be reasonable in patients younger
than 50 years of age who have a typical anal fissure. In patients with a family
history of colon cancer or age greater than 50 (and, therefore, at higher risk
for colon cancer), a colonoscopy that examines the entire colon is recommended.
Atypical fissures that suggest the presence of other diseases, as discussed
previously, require other diagnostic studies including colonoscopy and upper
gastrointestinal (UGI) and small intestinal X-rays.