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Abstract
In this paper Authors evaluate data of their experience
about children affected by anal rhagades and compare the results to a
previous study performed on adults patients.
They illustrate their protocol of treatment after an analysis about physiopathological
aspects of anal fissure in pediatric age.
Key words: Anal fissure, proctology.
Italian abstract
Gli Autori valutano i dati della casistica su
bambini affetti da ragade anale comparandoli con i risultati di un precedente
studio condotto su adulti che presentavano la stessa patologia.
Dopo aver individuato le caratteristiche fisiopatologiche della ragade
anale in età pediatrica vengono considerate le modalita di trattamento.
Anal fissure is a common disease of the anal canal which is characterised
by anal pain, stipsis, pruritus, tenesmus and proctorrhagia. Disease's
incidence in children is as high as in adults. However the cause and pathogenesis
of this condition may be different in children from that reported in the
adults. As consequence of this the treatment of choice may differ between
the two groups.
We review in this paper our general experience with anal fissure in children.
Additionally we compared the results of this study with those reported
previously in another study conducted on adults with the intention to
determine the physiopathologic characteristic of this condition and its
modalities of treatment.
Study population
This study included 30 children (19 female, mean age 4,2
years (range: 18 months-9 years)) with anal fissure. All children underwent
a careful proctologic visit with anoscopy in order to exclude other associated
ano-rectal disease.
Anal fissure was present in the medial-posterior aspect of the anal canal
in 24 patients and in the medial-anterior aspect in 2. In 4 case multiple
anal fissures were present.
Symptoms are shown in table 1. Stipsis was the most common symptom recorded
and was observed in all children.
Table 1 : Presentig symptoms of anal fissure in 30 children.
| SYMPTOMS |
No.Pts |
% |
|
- - pain during or after defecation
- rectal bleedig
- costipation
- anal itching
- tenesmus
|
28
20
30
11
9 |
93.3
66.6
100
36.6
30 |
Table 2 shows the data of 117 adult patients with anal fissure
published previously in another study.
Table 2 : - presenting symptoms of anal fissure in 117 patients.
| SYMPTOMS |
No.Pts |
% |
|
- pain during or after defecation
- rectal bleedig
- costipation
- anal itching
- tenesmus
|
113
94
90
40
38 |
96.6
80.3
76.9
34.2
32.5 |
The results of the two groups were compared. In particular we found that
the incidence of stipsis, pruritus and tenesmus was similar between the
two groups. Anal serous discharge was not assessed properly in children
as 18 (10 female) of whom were still wearing the nappy. However the incidence
of proctorrhagia was higher in adults. Significantly stipsis was present
with a higher incidence in children than in adults (100% vs 77%). In few
adult cases anal fissure was associated with diarrhoea.
Initially the treatment of choice for children was always conservative.
We first tried to solve the stipsis with laxatives and a diet rich in fibres.
In few cases in smaller children we advised the use of olive oil just before
defecation. In other cases we found useful the application of an anaesthetic
cream to decrease the severity of the pain.
Symptoms disappeared completely in children after 5-10 days of conservative
treatment and anal fissures healed after 10-15 days. The treatment was anyway
continued for several weeks after the anal fissures were healed. None of
the children received surgical treatment for this condition. On the contrary
all adults underwent lateroshynterectomy which was successful in 80% of
cases.
Discussion
The anal canal has a relatively weak area in the medial-posterior
aspect of the internal sphincter due to the its angle, its relative posterior
fixety and the elliptic form of the superficial part of the external sphincter.
This is the area where commonly idiopatic anal fissures arise in males.
This " locus minor resistentiae" is called Brick's space.
On the other hand in females there is a weak zone at the level of the
anterior commissure among the vulva, the vagina and the tendineous center
of the perineum. This explains why anterior anal fissure is found almost
exclusively in females.
Initially anal fissure presents itself as triangular mucosal ulcer localized
between the anal border and the denate line. White muscular fibres of
the internal sphincter are successively exposed.
Several theories have been evalued to explain the onset of anal fissure:
Infectous theory: the fissure originates from an infection of Morgagni's
cripts;
Vascular theory: the fissure arises from an area of deficent haematic
perfusion;
Meccanical theory: the fissure is a conseguence of repeted traumas due
to the passage of excessively hard and voluminuos faeces.
Recently, also the role of the hypertone of the sphincter has been made
clear: it creates areas of chronic ischemia (vascular theory) and reduces
the elastic response of the anus to the passage of faeces, thus enhancing
their traumatic effect.
The hypertone then, is not just a consequence of a reflex contraction
caused by pain during the passage of faecal material on the fissure but
it is also a cause for the onset of the disease itself. Moreover the presence
of a hypertone retards or impedes the healing of the lesion. The therapeutic
value of sphincterotomy is based on these considerations. Sphincterotomy
consists of a bridge interruption of the internal sphincter (about 2/3)
either on the medial posterior line ( medial posterior sphincterotomy)
or laterally ( Parks' lateral sphincterotomy ). The interruption of the
sphincter leads to immediate disappearance of pain and healing of the
fissure.
This procedure is effective in 97% of pts and it is nowadays considered
the most resolutive treatment in adults. Nonetheless, it can't be indicated
for paediatric patients if not in exceptional cases.
Sphincterial hypertone does not have the same importance in the onset
on the paediatric fissures as it does in the adult. This is evident in
comparing the data reported in the tables. In children stipsis is present
with a percentage of 100%, while in adult it amounts to only 76.9% of
cases. Moreover diarrhoea has been evidenced in 12 adult patients. As
it is known, diarrhoea causes an increase of the tone of the sphincter.
Thus explaining the high incidence of fissures in patients with colitis.
It is possible to hypothesise that anal fissure in children as an exclusive
consequence of the trauma induced by too voluminous or hard faeces.
For this reason we have, in accord with what is reported by literature,
to adopt a conservative therapy based on a local treatment and on making
the evacuation process regular, always obtaining the disappearance of
the pain and the healing of the fissure.
According to this results we then consider not useful to perform surgical
treatment on the internal anal sphincter. In children, in fact, this muscular
structure is particularly delicate since it is still growing. Is then
impossible to perform a perfectly calibrated sphincterotomy without risking
severe damage that may compromise continence during adulthood.
References
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