A 39-year-old man with a history of chronic constipation comes to the physician with severe anal pain for the past 2 months. Bowel movements worsen the pain, and there is also persistent pain without stool passage. He reports a small amount of blood on the toilet paper after bowel movements. His family history is notable for irritable bowel syndrome in his mother and sister.
The patient's blood pressure is 138/78 mm Hg, pulse is 84/min, and respirations are 14/min. Physical examination shows a soft and nontender abdomen with normoactive bowel sounds. There is no hepatomegaly or splenomegaly. Rectal examination is limited due to significant pain on insertion of the finger and a tight anal sphincter. Small external hemorrhoids are noted.
Laboratory results are as follows:

Colonoscopy is notable for moderate-size internal hemorrhoids, mild diverticulosis, and posterior anal fissure on external examination under sedation.
In addition to dietary modification and stool softeners, which of the following is the most appropriate next step in management?

Question

A 39-year-old man with a history of chronic constipation comes to the physician with severe anal pain for the past 2 months.  Bowel movements worsen the pain, and there is also persistent pain without stool passage.  He reports a small amount of blood on the toilet paper after bowel movements.  His family history is notable for irritable bowel syndrome in his mother and sister.
The patient's blood pressure is 138/78 mm Hg, pulse is 84/min, and respirations are 14/min.  Physical examination shows a soft and nontender abdomen with normoactive bowel sounds.  There is no hepatomegaly or splenomegaly.  Rectal examination is limited due to significant pain on insertion of the finger and a tight anal sphincter.  Small external hemorrhoids are noted.
Laboratory results are as follows:

Colonoscopy is notable for moderate-size internal hemorrhoids, mild diverticulosis, and posterior anal fissure on external examination under sedation.
In addition to dietary modification and stool softeners, which of the following is the most appropriate next step in management?

Quizplus · Accepted Answer

This patient's presentation is consistent with anal fissure, a benign tear in the anal mucosa due to high pressures. Fissures can be primary or secondary (eg, Crohn's disease) and occur most commonly in the posterior anal midline. Patients usually present with tearing pain during bowel movements, blood on the toilet paper or stool surface, and perianal pruritus. Diagnosis is made clinically with history and physical examination showing anal laceration. Patients with rectal bleeding should undergo endoscopy (sigmoidoscopy or colonoscopy for those age > 50). Those with lateral or anterior fissures and other clinical features suggesting inflammatory bowel disease should undergo colonoscopy and small-bowel imaging. Further investigation is also indicated for patients not responding to conservative treatment. Topical nitroglycerin improves blood flow to the anal area to promote wound healing and is preferred for acute fissures in combination with dietary changes. Botulinum toxin injection into the anal area also results in rapid healing and is recommended for patients refractory to topical nitroglycerin. Oral therapies (eg, nifedipine or diltiazem) are not usually recommended due to poor efficacy and increased risk of side effects. Anal fissures can be prevented by avoiding constipation with increased fiber and fluid intake, avoiding anal trauma, and keeping the anal area dry and clean. (Choice A) Hydrocortisone cream can be used for inflamed hemorrhoids or as adjunctive treatment for ulcerative colitis, but it is not first-line treatment for anal fissures. (Choice B) Surgery (eg, lateral sphincterotomy) is reserved for patients who continue to have anal fissures despite medical therapy or for chronic fissures. (Choice D) Oral metronidazole is first-line treatment for uncomplicated perianal fistulas in Crohn's disease following drainage of abscesses. It is not recommended for treatment of anal fissures. (Choice E) Hemorrhoids usually present with painless bleeding, pruritus, or fecal soilage. Pain is usually due to a thrombosed hemorrhoid (external hemorrhoids more commonly than internal hemorrhoids). This patient does not have a thrombosed hemorrhoid, and his symptoms suggest pain from an anal fissure. Dietary management (eg, adequate fluid and fiber intake) is the primary medical treatment for symptomatic hemorrhoids. Band ligation is recommended for patients who are refractory to medical treatment. Educational objective: Topical nitroglycerin improves blood flow to the anal area to promote wound healing and is preferred for acute fissures. Other conservative measures include adequate fluid and fiber intake, sitz baths, and keeping the anal area dry and clean. Botulinum toxin injection into the anal area also results in rapid healing and is recommended for patients refractory to topical nitroglycerin. __________ References: Anal fissure. (http://www.ncbi.nlm.nih.gov/pubmed/20109631) Non surgical therapy for anal fissure. (http://www.ncbi.nlm.nih.gov/pubmed/22336789)

A 39-Year-Old Man with a History of Chronic Constipation Comes