Anal Fissür
Özet
Anal fissür, dentat çizgiden anal vergeye kadar uzanan ve genellikle lokal travma veya sert dışkılama kaynaklı oluşan anoderm yırtıklarıdır. İç sfinkterde spazm, artan istirahat basıncı (90 mm-Hg üzeri) ve yetersiz kan akımı kronikleşmeye yol açar; vakalar çoğunlukla posterior duvarda orta hatta yerleşir. En sık belirtileri dışkılama sırasında bıçak saplanır gibi ağrı ve parlak kırmızı kanamadır. Atipik yerleşimlerde Crohn veya tüberküloz gibi sistemik hastalıklar araştırılmalıdır. Akut vakalar sıvı-lif alımı, 40 °C sıcak su oturma banyosu ve nifedipin/diltiazem gibi topikal kalsiyum kanal blokerleri veya nitratlar içeren ameliyatsız yöntemlerle tedavi edilebilir; geçici inkontinans riski barındıran botulinum toksini enjeksiyonu da bir seçenektir. Medikal tedaviye dirençli kronik fissürlerde ise cerrahi olarak iç sfinkter kasının bir kısmının kesilmesine dayanan lateral internal sfinkterotomi ya da %98 başarı oranı sunan anoderm ilerletme flepleri uygulanır.
Anal fissure is defined as tears in the anoderm extending from the dentate line to the anal verge, typically initiated by local trauma or hard defecation. A vicious cycle of internal sphincter spasm, increased resting pressure exceeding 90 mm-Hg, and consequent mucosal ischemia drives the pathogenesis, with most fissures located at the posterior midline due to lower vascularity in this region. The primary symptoms include sharp, knife-like pain during defecation and bright red bleeding, while atypical locations necessitate evaluating underlying systemic conditions such as Crohn's disease or tuberculosis. Acute fissures are managed non-operatively through lifestyle and medical interventions including increased fluid and fiber intake, 40 °C warm sitz baths, topical nitrates, or calcium channel blockers like nifedipine and diltiazem; botulinum toxin injection presents another temporary chemical sphincterotomy option despite minor incontinence risks. For chronic, treatment-resistant cases, surgical interventions are required, utilizing either lateral internal sphincterotomy, which involves dividing a portion of the internal sphincter muscle, or advancement flaps, which cover the defect with a skin graft and achieve high success rates.
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