, Franz Raulf2 and Horst Mlitz3
(1)
Department of Proctology, Clinic for Dermatology at RWTH Aachen University, Aachen, Germany
(2)
Medical Center of Coloproctology, Münster, Germany
(3)
Medical Center of Coloproctology, Saarbrücken, Germany
The definition of chronic anal fissure is inconsistent. Some authors define it on the basis of its time of existence (longer than 6, 8, or 12 weeks), others on the basis of morphological criteria like the depth of the defect, the condition of the edges of the fissure, or the existence of secondary changes such as skin tag, hypertrophied anal papilla, cryptitis, or fistula. All these clinical manifestations can be chronic anal fissure components, separately or jointly.
Due to these varying definitions, it is not astonishing that therapy studies arrive at different results. For example, studies examining the use of glyceryl trinitrate yield healing rates between 41 and 85% (n = 12), diltiazem studies (n = 11) state rates between 41 and 94%, and botulinum toxin therapy studies (n = 22) show rates between 43 and 92% of the cases. These highly divergent results are particularly attributed to the fact that secondary changes in their different manifestations have not been taken into account sufficiently enough. Nevertheless, their relevance to the healing process was established in several studies.
Brühl et al. (2011) distinguished anal fissures associated with hypertrophied anal papilla and/or skin tags from those without such changes. They treated their patients with 0.3% glyceryl trinitrate ointment. There was not a single case of healing in the first collective, but 80% of the anal fissures treated in the second collective healed completely.
When sphincterotomy is performed as therapy for anal fissure, the concurrent ablation of secondary changes seems to be important in terms of healing, relapse, and patient satisfaction. Therefore, Gupta (2004) insists on the removal of hypertrophied anal papillae as an essential element in the therapy for anal fissure.
Nifedipine trials also demonstrate the inconsistency in the definitions of chronic anal fissure (Table 4.1).
Table 4.1
Definitions of chronic anal fissure in nine nifedipine trials
Author (year) | Definition |
---|---|
Cook et al. (1999) | Duration of >2 months |
Perrotti et al. (2002) | Duration of >2 months |
Agaoglu et al. (2003) | Duration of >2–3 months, transverse fibers of internal anal sphincter muscle visible |
Ezri and Susmallian (2003) | Duration of >2–3 months, transverse fibers of internal anal sphincter muscle visible or existence of anal skin tag |
Ho and Ho (2005) | Duration of >1.5 months and/or transverse fibers of internal anal sphincter muscle visible and presence of anal skin tag and/or existence of anal papilla |
Mustafa et al. (2005) | Duration of >2–3 months and transverse fibers of internal anal sphincter muscle visible and/or existence of anal skin tag |
Lysy et al. (2006) | Transverse fibers of internal anal sphincter muscle visible, existence of anal skin tag |
Tranqui et al. (2006) | Transverse fibers of internal anal sphincter muscle visible |
Katsinelos et al. (2006) | Duration of >2 months, transverse fibers of internal anal sphincter muscle visible |
The ICD-10 code differentiates only between acute anal fissure (K60.0) and chronic anal fissure (K60.1). Considering the reasons mentioned before, this classification is insufficient.
To our knowledge, a classification of chronic anal fissures was published for the first time ever by Thornton et al. (2005):
Grade 1: fibers of the internal anal sphincter muscle not visible
Grade 2: deep fissure, fibers of the internal anal sphincter muscle visible
Grade 3: deep, undermined fissure edges
Grade 4: fissure with marginal fistula
We believe this classification to be insufficient and suggest a differentiation of anal fissures which includes the acute clinical syndrome as well as depth and also the existence of secondary changes. A stringent classification of anal fissure is desirable with regard to the choice of therapy. We recommend therefore our novel classification published in 2010 (Table 4.2).
Stage | Anal fissure | Secondary changes |
---|---|---|
I | Acute | None |
II | Chronic, shallow | None |
II A | Chronic, shallow | + hypertrophied anal papilla |
II B | Chronic, shallow | + anal skin tag |
II C | Chronic, shallow | + cryptitis |
II D | Chronic, shallow | + fistula |
III | Chronic, deep fibers of internal anal sphincter muscle visible | None |
III A | Chronic, deep fibers of internal anal sphincter muscle visible | + hypertrophied anal papilla |
III B | Chronic, deep fibers of internal anal sphincter muscle visible | + anal skin tag |
III C
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