A 33-year-old man comes to the office due to persistent anal pain. Two months ago, the patient experienced severe anal pain associated with bowel movements. Evaluation revealed an anal fissure and external hemorrhoids for which he was treated with stool softeners and topical nitroglycerine. His symptoms have persisted despite adherence with the medical therapy and high-fiber diet. He reports no history of anal trauma or anal intercourse.
Vital signs are within normal limits. Rectal examination is painful and reveals a posterior midline anal fissure, large skin tag, and external hemorrhoids with no thrombosis. The remainder of the physical examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits. Which of the following is the most appropriate next step in management of this patient's disorder?

Question

A 33-year-old man comes to the office due to persistent anal pain.  Two months ago, the patient experienced severe anal pain associated with bowel movements.  Evaluation revealed an anal fissure and external hemorrhoids for which he was treated with stool softeners and topical nitroglycerine.  His symptoms have persisted despite adherence with the medical therapy and high-fiber diet.  He reports no history of anal trauma or anal intercourse.
Vital signs are within normal limits.  Rectal examination is painful and reveals a posterior midline anal fissure, large skin tag, and external hemorrhoids with no thrombosis.  The remainder of the physical examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits.  Which of the following is the most appropriate next step in management of this patient's disorder?

Quizplus · Accepted Answer

11ec193a_980c_8e6d_853d_dd889a9a373e_MD0002_00 This patient has a persistent anal fissure despite optimal medical therapy. Acute fissures tend to be superficial and present with severe pain; chronic fissures are less painful and may appear hypertrophied with skin tags. Diagnosis is usually made clinically, with physical examination revealing anal laceration, most commonly in the posterior anal midline (possibly due to decreased blood supply compared to other areas in the anal canal, leading to inadequate wound healing). However, further evaluation is indicated for patients with the following: Anal fissures with atypical features: eccentrically located (lateral, anterior), multiple, painless, very deep, recurrentRectal bleeding: requires sigmoidoscopy if age <50 and colonoscopy if age ≥50Failure to respond after 8 weeks of optimal medical therapy, including topical vasodilators (eg, nitroglycerin, nifedipine), stool softeners, and advice to supplement fiber intake Anal fissures with atypical features: eccentrically located (lateral, anterior), multiple, painless, very deep, recurrent Anal fissures with atypical features: eccentrically located (lateral, anterior), multiple, painless, very deep, recurrent Rectal bleeding: requires sigmoidoscopy if age <50 and colonoscopy if age ≥50 Rectal bleeding: requires sigmoidoscopy if age <50 and colonoscopy if age ≥50 Failure to respond after 8 weeks of optimal medical therapy, including topical vasodilators (eg, nitroglycerin, nifedipine), stool softeners, and advice to supplement fiber intake Failure to respond after 8 weeks of optimal medical therapy, including topical vasodilators (eg, nitroglycerin, nifedipine), stool softeners, and advice to supplement fiber intake In patients with Crohn disease, anal fissures most frequently (80%) present as posterior midline fissures but can present atypically (eg, eccentric location) in 20% of cases. Complications include fistula and abscess formation. Therefore, patients such as this one with with nonhealing or atypical anal fissures require a colonoscopy and small-bowel imaging to rule out Crohn disease. (Choice A) Biopsy is usually performed for suspected intestinal carcinoma; malignancies commonly appear as strictures or perianal fistulas with excessive granulation tissue. These are more common in patients with long-standing Crohn disease. This patient's anal fissure has been present for only 2 months; malignancy is unlikely to develop within this time frame. (Choice C) The chancre in primary syphilis may present as an anal ulcer or fissure but is typically painless and resolves within 4-6 weeks. In addition, rectal involvement generally occurs in patients engaging in anal intercourse. (Choice D) Hemorrhoids usually present with painless bleeding, pruritus, or fecal soilage. Pain is usually due to a thrombosed hemorrhoid (more common with external than internal hemorrhoids). Rubber band ligation is reserved for treatment of symptomatic internal hemorrhoids that are refractory to conservative management. (Choice E) Celiac disease typically presents with fatigue, iron-deficiency anemia, nutritional deficiencies (eg, vitamin D, calcium), and gastrointestinal symptoms (eg, diarrhea with gluten intake, steatorrhea, flatulence). The absence of these symptoms in this patient makes celiac disease less likely. Educational objective: Crohn disease is a common cause of atypical anal fissures. Patients with atypical features (eg, lateral or anterior location, multiple, painless, very deep, recurrent, nonhealing) or those who do not improve after 8 weeks of optimal therapy should undergo a colonoscopy for evaluation of Crohn disease. __________ References: Anal fissure in Crohn's disease: a plea for aggressive management. (http://www.ncbi.nlm.nih.gov/pubmed/7587755) Perianal Crohn disease: predictors of need for permanent diversion. (http://www.ncbi.nlm.nih.gov/pubmed/15849515) Perianal ulceration: a case of tuberculosis cutis orificialis. (http://www.ncbi.nlm.nih.gov/pubmed/15857468)

A 33-Year-Old Man Comes to the Office Due to Persistent