What are the guideline sources, guidelines and references for Anal fissure ?
Guideline sources The following summarized guidelines for the evaluation and management of anal fissure are prepared by our editorial team based on guidelines from the American Society of Colon and Rectal Surgeons (ASCRS 2023; 2017), the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Gastroenterology (ACG 2021), and the Association of Coloproctology of Great Britain and Ireland (ACPGBI 2008). 1 2 3 4 5 6 6 6 7 7 8 Definition Anal fissures refer to an anorectal disorder characterized by a tear in the squamous epithelium of the anus, distal to the dentate line. Fissures are defined as acute if present for less than 6 weeks, and they are defined as chronic if present for more than 6 weeks. 6 7 Epidemiology Various risk factors increase the risk of anal fissures, mediating their effects via mechanical tissue trauma, ischemia of the anal canal, impaired sphincter structure or function, or anal hypertonicity. 6 Pathophysiology https://web.pathway.md/diseases/recq5R49DVcBid2l3 1/5 6/23/23, 2:35 AM Anal fissure Pathway The annual incidence of anal fissures in the United States is estimated at 110 cases per 100,000 person-years. 8 Disease course Anal fissures may cause clinical manifestations of anal pain, spasm, and/or bleeding with defecation. 6 Prognosis and risk of recurrence Medical treatment is associated with over 70% success rates. Surgical treatment, which is typically reserved for patients in whom medical therapy fails, yields excellent outcomes. 7 Guidelines 1. Screening and diagnosis Etiology: recognize that anal fissures associated with internal anal sphincter hypertonia are probably ischemic in nature. B Diagnosis: diagnose anal fissures based on medical history and physical examination findings. B Differential diagnosis: As per WSES 2021 guidelines, consider eliciting a focused medical history, performing a complete physical examination and obtaining laboratory tests based on the suspected associated illness, to rule out other causes in patients with atypical acute anal fissures. C As per ASCRS 2017 guidelines, recognize that less common causes of anal fissures include Crohn's disease, sexually transmitted diseases, and low-pressure fissures. B 2. Diagnostic investigations Diagnostic imaging: Insufficient evidence to recommend obtaining imaging investigations in patients with typical acute anal fissures. Consider obtaining endoscopy, CT, or endoanal ultrasound in patients with atypical acute anal fissures only in case of suspected concomitant IBD, anal or colorectal cancer, or occult perianal sepsis. C Laboratory tests: insufficient evidence to recommend obtaining biochemical investigations in patients with typical acute anal fissures. I 3. Medical management Indications for non-operative management: https://web.pathway.md/diseases/recq5R49DVcBid2l3 2/5 6/23/23, 2:35 AM Anal fissure Pathway As per ASCRS 2023 guidelines, offer nonoperative management as first-line therapy in patients with acute anal fissures. B As per WSES 2021 guidelines, offer nonoperative management as first-line therapy in patients with acute anal fissures. B As per ACPGBI 2008 guidelines, recognize that conservative management will heal a proportion of acute anal fissures. A Topical nitrates: As per ASCRS 2023 guidelines, consider offering topical nitrates in patients with anal fissures, although headache symptoms may limit their efficacy. B As per ACPGBI 2008 guidelines, offer topical glyceryl trinitrate in patients with anal fissures. A Topical calcium channel blockers: As per ASCRS 2023 guidelines, offer CCBs as first-line therapy in patients with chronic anal fissures. B As per ACG 2021 guidelines, offer local CCBs as first-line medical treatment in patients with chronic anal fissures. B As per ACPGBI 2008 guidelines, offer topical diltiazem as first-line therapy in patients with anal fissures. Inform patients about pruritis ani. A Topical antibiotics: consider offering topical antibiotics in patients with acute anal fissures in case of potentially reduced therapeutic compliance or poor genital hygiene. C Pain management: consider offering topical anesthetics and common painkillers in patients with acute anal fissures in case of inadequate pain control. C 4. Nonpharmacologic interventions Dietary modifications: advise dietary and lifestyle changes with increased fiber and water intake in patients with acute anal fissures. B 5. Therapeutic procedures Botulinum toxin injections: As per ASCRS 2023 guidelines: Administer botulinum toxin injection as first-line therapy in patients with chronic anal fissures and as second-line therapy following failed treatment with topical therapies. B Insufficient evidence to recommend repeat botulinum toxin injection in patients with recurrent anal fissures, although short-term outcomes have shown good healing rates with a low risk of fecal incontinence. I As per WSES 2021 guidelines, insufficient evidence to recommend botulinum injections in patients with acute anal fissures. I https://web.pathway.md/diseases/recq5R49DVcBid2l3 3/5 6/23/23, 2:35 AM Anal fissure Pathway As per ACG 2021 guidelines, consider performing botulinum toxin A injections in patients failed CCBs or as an alternative to CCBs. C As per ACPGBI 2008 guidelines, consider administering botulinum toxin injection in patients with anal fissures resistant to topical glyceryl trinitrate or diltiazem. B Anal dilatation: As per WSES 2021 guidelines: Do not perform manual dilatation in patients with acure anal fissures. D Insufficient evidence to recommend for or against controlled anal dilatation in patients with acute anal fissures. I As per ACPGBI 2008 guidelines, do not perform anal dilatation for the management of patients with anal fissures. D 6. Surgical interventions Indications for surgery: Avoid performing surgery in patients with acute anal fissures. D Consider performing surgery in patients with anal fissures in the chronic phase not responding after 8 weeks of nonoperative management. B Lateral internal sphincterotomy: As per ASCRS 2023 guidelines, consider performing lateral internal sphincterotomy in selected pharmacologically na ve patients with chronic anal fissures. B Show 4 more As per ACG 2021 guidelines, perform lateral internal sphincterotomy as the surgical treatment of choice in patients with chronic anal fissures failed to heal with nonoperative management. A As per ACPGBI 2008 guidelines, reserve lateral sphincterotomy for patients failed medical treatment. A Anocutaneous flap: As per ASCRS 2023 guidelines: Consider performing anocutaneous flap surgery as an alternative to lateral internal sphincterotomy in patients with chronic anal fissures with a decreased risk of fecal incontinence compared with lateral internal sphincterotomy and comparable healing rates. C Consider performing anocutaneous flap surgery in addition to botulinum toxin injections or lateral internal sphincterotomy to decrease postoperative pain and allow for primary wound healing. C As per ACPGBI 2008 guidelines, perform anal advancement flap surgery in patients with a low resting anal pressure A . Consider performing rotational or V-Y flap techniques. B 7. Specific circumstances https://web.pathway.md/diseases/recq5R49DVcBid2l3 4/5 6/23/23, 2:35 AM Anal fissure Pathway Pediatric patients: offer conservative management initially in pediatric patients with anal fissures. Offer local glyceryl trinitrate or CCBs if conservative management fails. Reserve lateral sphincterotomy or fissurectomy for cases failing to heal with medical treatment. B References 1. K L R Cross, E J D Massey, A L Fowler et al. The management of anal fissure: ACPGBI position statement. Colorectal Dis. 2008 Nov;10 Suppl 3 1 7. Open 2. Antonio Tarasconi, Gennaro Perrone, Justin Davies et al. Anorectal emergencies: WSES AAST guidelines. World J Emerg Surg. 2021 Sep 16;16 1 48. Open 3. Arnold Wald, Adil E Bharucha, Berkeley Limketkai et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1;116 10 1987 2008. Open 4. Jennifer S Davids, Alexander T Hawkins, Anuradha R Bhama et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Anal Fissures. Dis Colon Rectum. 2023 Feb 1;66 2 190 199. Open 5. Stewart DB Sr, Gaertner W, Glasgow S et al. Clinical Practice Guideline for the Management of Anal Fissures. Dis Colon Rectum. 2017 Jan;60 1 7 14. Open 6. Zaghiyan KN, Fleshner P. Anal fissure. Clin Colon Rectal Surg. 2011 Mar;24 1 22 30. Open 7. Latif A, Ansar A, Butt MQ. Morbidity associated with treatment of chronic anal fissure. Pak J Med Sci. 2013 Sep;29 5 1230 5. Open 8. Mapel DW, Schum M, Von Worley A. The epidemiology and treatment of anal fissures in a population- based cohort. BMC Gastroenterol. 2014 Jul 16;14 129. Open https://web.pathway.md/diseases/recq5R49DVcBid2l3 5/5