Pediatric Surgery for Anal Fissure Clinical Presentation

Updated: Apr 08, 2016
  • Author: Brian P Gillett, MD; Chief Editor: Philip Glick, MD, MBA  more...
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Presentation

History

The diagnosis is usually made through a careful history and physical examination. A history of constipation is often elicited. The child may cry with bowel movements, and streaks of bright red blood on the surface of hard stool, on the diaper, or on the toilet paper after a bowel movement may be identified by the patient or family.

It is important to remember that underlying systemic illness frequently manifests with anal lesions. Thus, pertinent negatives, such as fever, rash, oral or skin lesions, weight loss, diarrhea, and abdominal pain, should be excluded. Also, psychological problems and stressors that may provoke stool negativism should be elicited.

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Physical Examination

The diagnosis is established by inspecting the anal region. For this examination, the parents should hold the child's hips in acute flexion while the examiner separates the buttocks, retracting the perianal skin folds. For older children, the anoderm may be spread apart while the child bears down because this maneuver facilitates visualizing the fissure.

If a fissure is identified, a digital examination is best avoided because it is likely to elicit unnecessary pain and sphincter spasm. However, if a fissure is not observed, a digital examination should be performed to rule out other pathology. If the examination is limited by pain and the diagnosis remains unclear, an examination under anesthesia should be pursued.

The fissure appears as a minor laceration, usually in the midline, and is more often posterior than anterior. If the fissure is chronic, a small external skin tag (ie, sentinel tag) may be identified at the base of the laceration; this represents epithelialized granulomatous tissue secondary to chronic inflammation.

If a fissure is suspected, palpation of the abdomen is essential to check for palpable masses (stool) in the left lower quadrant.

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