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Key Features

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  • Defined as a slit-like tear in the squamous epithelium of the anus that usually occurs secondary to the passage of large, hard fecal masses, typically at the superior and inferior aspects of the anus

  • Anal stenosis, anal crypt abscess, and trauma can be contributory factors

  • Sexual abuse must be considered in children with large, irregular, or multiple anal fissures

  • The infant or child with anal fissure typically cries with defecation and will try to hold back stools

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Clinical Findings

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  • May be the presenting sign of Crohn disease in older children

  • Sparse, bright red bleeding is seen on the outside of the stool or on the toilet tissue following defecation

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Diagnosis

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  • Can often be seen if the patient is examined in a knee-chest position with the buttocks spread apart

  • When a fissure cannot be identified, it is essential to rule out other causes of rectal bleeding such as

    • juvenile polyp

    • perianal inflammation due to group A β-hemolytic streptococcus

    • inflammatory bowel disease

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Treatment

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  • Should be treated promptly to break the constipation, fissure, pain, retention, and constipation cycle

  • A stool softener should be given

  • Warm Sitz baths after defecation may be helpful

  • Rarely, silver nitrate cauterization or surgery is indicated

  • Anal surgery should be avoided in patients with Crohn disease because of the high risk of recurrence and progression after surgery

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