The anal canal is the last 4 cm of the alimentary tract and is developed from the anorectal canal and proctoderm .Like the rest of the gut it is a tube of muscle but the fibers are all muscular , consisting of the internal and external anal sphincters , which are composed of visceral and skeletal muscle respectively . These sphincters , assisted by the configuration of the mucous membrane , hold it continually closed except for the temporary passage of flatus and faeces3.

The very common problem of anal fissure was first described in 1829 by Recamier 2, who recommended stretching the anal sphincter to treat the condition .Anal fissure is a common disorder for which many people do not seek medical advice The typical anal fissure in the midline posteriorly from the pectinate line to the anal verge. Pain on defecation is the outstanding symptom of anal fissure. Although the tear is usually small , it can be very painful as the anus is very sensitive . Treatment of chronic anal fissure has shifted in recent years from surgical to medical methods . Traditional surgery which permanently weakens the internal sphincter is associated with the risk of incontinence.

Even though there are effective homoeopathic medicines for this disease , no body has undertaken a scientific study on this matter based on statistical data . This is an attempt to do a scientific study based on statistical data .

AIM OF STUDY
To assess the efficacy of Homoeopathic medicines in the treatment of anal fissure

SURGICAL ANATOMY
The anal canal is a tubular structure 3 to 4 cm in length extending from the perineal skin to the lower end of the rectum and is demarcated by the proximal and distal margins of the internal sphincter. It normally exists as a collapsed anteroposterior slit.The junction between the anoderm and perineal skin is known as the anal verge, or Hilton’s line, identified microscopically by the appearance of cutaneous adnexae. The anoderm is a specializedepithelium rich in nerves but devoid of secondary skin appendages3.

The pectinate or dentate line is located at the very center of the analcanal. The dentate line is the true mucocutaneous junction located 1-1.5 cm above the anal verge.

For practical purposes surgeons usually define the surgical anal canal , extending from the anal verge to the anorectal ring , which is the circular upper border of the puborectalis that is palpable by the digital rectal examination. The anorectal ring is 1-1.5 cm above the dentate line.

The segment of anal canal located immediately below this line exhibits a number of longitudinal folds known as anal columns of Morgagni. Homologous structures in the lower rectum are designated as rectal columns of Morgagni and the depressions between them as rectal sinuses of Morgagni. The anal columns are connected at thedentate line by the anal or semilunar valves. The latter form papillae are tooth like , raised projections located on the top of the anal columns, extending upward on to the rectum and representing ridges of sqamous mucosa directly joining the rectal mucosa .Both anal crypts and papillae show marked individual variations and are occasionally absent. The anal glands discharge into the anal crypts through anal ducts which penetrate the sphincters and sometimes extend into the perineal fat.

Anal Canal Musculature
The internal sphincter is the final condensation of the circular layer of gut muscle, and as such is controlled by autonomic nervous system. The involuntary muscle commences where the rectum passes through the pelvic diaphragm and ends at the anal orifice, where its lower border can be felt. The internal sphincter is 2.5 cm long and 2 to 5 mm thick. When exposed during life, it is pearly white in colour, and its individual transversely placed fibers can be seen clearly. Spasm and contracture of this muscle play a major part in tissue and other anal affections.

The longitudinal muscle is a combination of the longitudinal muscle coat of the rectum intermingled with fibers from puborectalis.The puborectalis fibers of the levator ani originate from the back of the pubic symphysis to form a U shaped sling. This sling helps to maintain the 80 degree angle between the axes of the rectum and anal canal and also compresses the anal canal into an anteroposterior slit9.

The fibers of the external sphincter are attached posteriorly to the coccyx . While anteriorly they are inserted to the mid perineal point in male, where as in female they fuse with sphincter vaginae. In life the external sphincter is pink in colour, and homogeneous. Unlike the pale internal sphincter muscle which is involuntary, the red external sphincter is composed of voluntary muscles. The longitudinal muscles, by traversing the internal and external sphincters to reach their insertions, serve to brace these sphincters.

The mucous membrane
The anal canal is lined by columnar epithelium in its upper part and by keratinized or nonkeratinized squamous epithelium in its lower part, which is known as pectin. At the interphase between the two, roughly corresponding to the pectinate line, there is a circular zone, 0.3 to 1.1 cm in width, with a glistening, wrinkled appearance made discontinuous by the presence of anal papillae. This zone is lined by epithelium known as transitional, intermediate, or cloacogenic, which resembles bladder epithelium10.

Blood supply
The superior rectal artery is the direct continuation of the inferior mesenteric artery and constitutes the chief arterial supply to the rectum . Opposite the third sacral vertebra the artery divides into a right and left branch. About half- down the rectum the right branch subdivides into an anterior and posterior branch. The terminal branches run straight downwards each in a column of Morgagni. Middle rectal artery arises from the internal iliac artery and passes in close proximity to the lateral ligament of the rectum to supply muscle coat and mucosa of the mid rectum. Often it is a comparatively small vessel. After division of the inferior mesenteric, in the operation of anterior resection, the middle and inferior rectal arteries can maintain an adequate blood supply as high as the recto–sigmoid junction.

The inferior rectal artery arises on each side as a branch of the internal pudendal artery crossing the upper part of the ischio rectal fossa , it breaks up into branches supply the anal sphincters, anal canal and the skin of anal margin.

The internal rectal venous plexus lies in the loose submucosa of the anal canal and extends from the level of dentate line to that of the ano-rectal ring. The plexus drains into about six collecting veins which are situated in the submucosa of the rectum . About half way up the rectum these branches passes through the rectal wall, and having reached the outside of the rectum , they unite to form the superior rectal vein, an important tributary of the portal vein. The middle rectal veins are small and drain into the internal iliac veins9.

The external rectal venous plexus lies under the skin of the anal canal below the dentate line and beneath the skin of the anal margin . communicating veins pass from the external rectal plexus to the internal rectal plexus beneath the anoderm. The lower part of the external rectal plexus drains into the internal pudendal veins and thence into the internal iliac veins , thus providing a link between the rectal and systemic venous systems

Lymphatic drainage of Anal canal
The rectal lymphatic flow is segmental and circumferential and follows the same distribution as the arterial blood supply. Lymph from the upper and middle rectum drains into the inferior mesenteric nodes. The lower rectum is primarily drained by the lymphatics which follow superior rectal artery and enter the inferior mesenteric nodes. Lymph from the lower rectum can also flow laterally along the middle and inferior rectal arteries, posteriorly along the middle sacral artery , or anteriorly through channels in the rectovesical and rectovaginal septum .These channels drain into the iliac nodes and subsequently to periaortic lymph nodes10 .

Lymphatics from anal canal above the dentate line drain via the superior rectal lymphatics to the inferior mesenteric nodes or laterally to the internal iliac lymph nodes . Below the dentate line , the lymphatics drain primarily to the inguinal nodes but can drain into the inferior or superior rectal lymph nodes as well.

Definition
Anal fissure is defined as an elongated ulcer in the long axis of the lower anal canal6.

Epidemiology
Incidence
The incidence of anal fissure decreases rapidly with age . Anal fissures are extremely common in infants but may occur at any age . Studies suggest 80 % of infants will have had an anal fissure by age one . Fissures are much less common among school – aged children than among infants . In adults , the condition is more common among females , and generally occurs during the meridian of life

Aetiology
The cause of anal fissure is not completely understood . In adults ,fissures may be caused by constipation , particularly when passing large , hard stools , or by prolonged diarrhoea . In older adults , anal fissure may be caused by decrease blood flow to the area .

Fissures occur most commonly in the midline posteriorly , the least protected part of anal canal . In males ninety percent of all fissures occur posteriorly and ten percent anteriorly . In females fissures on midline posteriorly are slightly commoner than anteriorly in the ratio 60 : 40 . The reason why other wise the midline posteriorly is so frequently affected is also not clearly known.

A probable explanation is that the posterior wall of the rectum curves forward from the hollow of the sacrum to join the anal canal, which then turns sharply backwards and relative fixation of the anal canal posteriorly . During defecation the pressure of a hard fecal mass is mainly on the posterior anal tissues, in which event the overlying epithelium is greatly stretched and, being relatively unsupported by muscle, is placed in a vulnerable position when a scybalous mass is being expelled . Another possible explanation is the divergence of the fibers of the external sphincter muscle posteriorly and the elliptical shape of the anal canal Possibly some cases are due to tearing down of anal valve of Ball6.

An anterior anal fissure is much more common in women, particularly in those who have borne children. This can be explained by the lack of support of the anal mucous membrane by a damaged pelvic floor and an attenuated perineal body. Prolonged diarrhoea with stretching of anal canal can cause a split in the anoderm

Spasm of the muscles around the anus may play a part in causing fissure . Increased anal sphincter tone is very often associated with stress The internal anal sphincter is thought to play a key role in the development of an anal fissure . Unlike the external anal sphincter, which can be tensed or relaxed voluntarily , there is no voluntary control of the internal sphincter . Because of the pain of a fissure , the internal anal sphincter may go in to spasm – causing a raised pressure with in the anus . This excess pressure makes it harder to pass the stool , making constipation worse , and contributing to a vicious circle . The spasm of the internal anal sphincter can also restrict the blood supply to the anal skin , which reduces its ability to heal . Increased anal sphincter pressure has been documented on anal manometry in patients with an anal fissure . The pain and irritation of the fissure result in spasm of the underlying internal sphincter muscle which then fails to relax during defecation, resulting in further tearing of the anoderm and deepening of the fissure to form an ulcer.

Fissures can also be caused by anal trauma resulting from anal intercourse , or laceration by a foreign object , laxative abuse etc

Fissures can rarely occur as a complication of anorectal operations uch as haemorrhoidectomy in which too much skin is removed . This results in anal stenosis and tearing of the scar when hard motion is passed1 .

Fissures can also occur in granulomatous infections such as venereal infections and inflammatory bowel diseases like ulcerative colitis or Crohn’s disease. Crohn’s disease or tuberculosis of the anal canal should be suspected when the fissure is in an atypical position ,indolent , less painful and multiple .

Pathology
The typical fissure is a longitudinal tear extending from the anal verge to the pectinate line in the posterior midline. In 15% of female patients and in 1% of males the tear is in the midline anteriorly. Because the fissure occurs in the stratified sensitive epithelium of the lower half of the anal canal , pain is the most prominent symptom. The pain and irritation of the fissure result in spasm of the underlying internal sphincter muscle which then fails to relax during defecation , resulting in further tearing the anoderm and deepening of the fissure to form an anal ulcer .

There are two types of fissure - in - ano . Acute fissure in ano is a tear of lower half of anal canal. There is hardly any inflammatory induration or oedema of its edges . Anal sphincter muscle spasm is always present6 .

The chronic fissure- in - ano is a deep canoe-shaped ulcer with thick oedematous margin . At the upper end of the ulcer there is hypertrophied papilla . The floor of which contains the lower third of the internal sphincter . The white fibers of the internal sphincter are found at the base of the ulcer . Inflammation causes swelling of the margins of the fissure , and an oedematous skin tag develops at the anal verge which is known as a ‘sentile pile’ – sentinel’ because it guards the fissure. The swollen anal valve at the upper extent of the fissure is called a hypertrophied anal papillae. Infection is common and may produce a perianal abscess , incision of which results in low anal fistula. Fissure is accompanied by spasm of the involuntary musculature of internal sphincter . In long standing cases , this muscle becomes organically contracted by infiltration of fibrous tissue4 .

Clinical Features
Anal fissure is more common in women and generally occurs during the meridian of life . It is uncommon in aged , because of muscular atony ; on the other hand , anal fissure is not rare in children and is sometimes encountered in infancy, and may cause acquired megacolon2.

Symptoms
The principal feature of a fissure is severe , sharp , agonizing , burning pain on defecation . The pain often starts during defecation , often overwhelming in intensity and lasting an hour or more . As a rule , it ceases suddenly , and the sufferer is comfortable until the next action of the bowel . Periods of remission occur for days or weeks. The patient tends to become constipated rather than go through the agony of defecation1.

Bleeding of fissure is variable . This is usually slight and consists of bright streaks on the stool or spots on toilet tissue.
A slight discharge accompanies fully established cases. Pruritus ani may be another symptom of this condition

Diagnosis
The diagnosis of anal fissure is usually readily established by consideration of the history combined with careful examination .

In case of some standing , a sentinel skin tag can usually be displayed. This , together with typical history and a tightly closed , puckered anus , is almost pathognomonic of the condition. By gently parting the margins of the anus , the lower end of the fissure can be seen . Because of the intense pain it causes , digital examination of the anal canal should not be attempted unless the fissure cannot be seen, it seems imperative to exclude major intra rectal pathology .In these circumstances , the local application of a surface anesthetic such as 5% xylocaine on a pledget of cotton wool, left in place for about 5 minutes , will enable the necessary examinations to be made . In early cases the edges of the fissure are impalpable ; in fully established cases , a characterestic crater which feels like a vertical button hole can be palpated , sphincter spasm is confirmed and indurated margins of the fissure are apparent . If the diagnosis must be established beyond doubt , a general anesthetic may be used.

Management
The pain of anal fissure is so great that the patient usually demands relief , and consequently many patients with an acute fissure present early . The object of all treatment for this condition is to obtain relaxation of the internal sphincter . Provided the complications are dealt with , the fissure will slowly heal as soon as all spasm has disappeared .

Conservative treatment
In cases where the fissure is acute and superficial and where inflammation is minimal , simple conservative measures will usually give relief . Regulation of bowel habits to avoid constipation and straining at defecation is very important . This is achieved by a high residue diet together with bran or other bulk laxative or hydrophilic
Substances3 .

To avoid straining , glycerlne suppositories may be needed to break the habit . Local medical treatment comprises the use of ointments and suppositories of various kinds . The value of these preparations is in the highest degree doubtful , but in the eyes of the patients they have the great psychological advantage of being applied directly to the site of origin of their symptoms .

Relaxation of the anal sphincter tone can be obtained with behavior modification . Also taking Sitz baths which involves soaking the anal area in warm water for 20 to 30 minutes several times daily is an excellent way to relax the anal sphincter tone and increase the blood flow to the area to promote healing .

Xylocaine 5 % in a water soluble lubricant is introduced with a fine nozzle into the anal canal. Following this a small anal dilator may be passed and if anaesthesia is adequate , it may be possible to introduce the largest dilator . Anal dilators are commonly made in three sizes and it may not be possible to introduce the largest dilator until several days have passed . The patient is instructed to pass a dilator twice a day for a month , by which time the fissure is usually healed. Laxatives are prescribed to ensure that the motions are soft , but the stools should not be made watery6

Operative measures
1. Anal dilatation –Lord’s procedure of anal dilatation
The simplest procedure is wide , forcible dilatation of the sphincter. Under general anaesthesia , the index and middle finger of each hand are inserted simultaneously into the anus and pulled apart to give maximal dilatation . The patient can go home the same day , but should be warned that there may be some fecal incontinence lasting possibly for a week or 10 days. The four – finger stretch produces uncontrolled fracturing of the internal sphincter even though it may give initial relief of symptoms . Approximately 40 % of patients treated this way develop recurrence , and a significant proportion are partially incontinent8 .

Should these measures prove ineffective , or if the fissure is chronic with fibrosis , a skin tag , or a mucous polypus , then surgical measures are advisable . General anaesthesia is best, though some surgeons use a local anaesthetic in order to anaesthetetise the nerves passing towards the rectum . In other situations a caudal anaesthetic is suitable .

2 . Lateral anal sphincterectomy
In this operation , the internal sphincter is divided away from the fissure itself- usually either in the right or left lateral position. The rocedure can be done by an open or closed method. Healing is usually complete within 3 weeks . The operation is more successful for acute than chronic fissures . 75% of cases are suitable for treatment by this method . The patients are able to leave the hospital in 3 or4 days , and the procedure can be done as an outpatient under local anaesthesia by an experienced surgeon. The procedure is performed with the patient in the prone , flexed position , usually with local anaesthesia . A success rate of 90 to 95 % is reported after lateral sphincterectomy and minor incontinence , such as leakage of mucus and gas , is reported in less than 10 percent5 .

3 . Dorsal fissurectomy and sphincterectomy .
The essential part of the operation is to divide the transverse fibers of the internal sphincter in the floor of the fissure . If a sentinel pile is present , this is excised . The ends of the divided muscle retract and a smooth wound is left . The after-treatment consists of attention of bowels , a daily bath , and the passage of an anal dilator until the wounds have healed , which usually takes about 3 weeks . Despite the presence of wound , there is little or no pain and the results are good. The disadvantage of this operation is the prolonged healing time- usually not less than 3 weeks and often longer – and occasionally a mild persistent mucus discharge . It is now reserved only for the most chronic or recurrent anal fissures , the majority being treated by the lateral sphincterectomy .
Excision of anal ulcer along with skin graft to limit convalescent period has not been succesful6

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