01Approach to the Critical Patient/attcp29

Red flags and immediate escalation

›High-risk triage

›Hemodynamic instability with rectal bleeding

›If syncope, persistent tachycardia, or hypotension, resuscitation pathway

›If ongoing large-volume hematochezia, lower GI bleed pathway

›Sepsis concern

›If fever and perineal pain out of proportion, necrotizing soft tissue infection pathway

›If perianal fluctuance with systemic symptoms, abscess drainage pathway

›Severe immunocompromise

›If neutropenia or advanced immunosuppression, early surgical consult for perianal infection concern

›Inability to complete anorectal exam due to pain

›If uncontrolled pain or concern for alternative diagnosis, urgent colorectal surgery evaluation

Key stabilization targets

›Physiologic targets

›Pain control sufficient for limited perianal inspection

›Topical anesthetic consideration before exam

›Bowel movement goals

›Soft stool daily without straining

›Hydration

›Oral fluids to support stool softening

Time-critical exclusions

›Diagnoses not to miss

›Perianal abscess

›Fluctuance, induration, fever, or night pain

›Thrombosed external hemorrhoid

›Acute tender perianal mass

›Fournier gangrene

›Toxic appearance, crepitus, skin discoloration, severe pain out of proportion

02History/hx41

Symptom pattern and triggers

›Presenting features

›Pain with defecation

›Sharp tearing pain during stool passage

›Pain lasting minutes to hours after stool

›Rectal bleeding

›Bright red blood on toilet paper or stool surface

›Bowel habit context

›Constipation and hard stool

›Diarrhea episodes

›Duration

›Less than 6 weeks consistent with acute fissure pattern

›6 weeks or more consistent with chronic fissure pattern

Risk factors and secondary causes

›Predisposing factors

›Recurrent constipation

›Low fiber intake

›Dehydration

›Opioid use

›Recurrent diarrhea

›Infectious gastroenteritis

›Laxative overuse

›Pregnancy and postpartum

›Recent delivery

›Constipation during pregnancy

›Prior anorectal surgery or instrumentation

›Endoscopy, enemas, anal trauma

›Secondary fissure clues

03Physical Exam/exam26

Focused anorectal exam

›Inspection and limited exam

›Perianal inspection

›Posterior midline linear tear typical location

›Anterior midline fissure possible

›Signs of chronicity

›Sentinel skin tag

›Hypertrophied anal papilla

›Exposed internal sphincter fibers

›Pain-limited exam strategy

›If severe spasm and pain, defer digital rectal exam

›If atypical features, exam under anesthesia consideration

Alternate diagnoses on exam

›Key differentiators

›Thrombosed external hemorrhoid

›Blue-purple tender perianal nodule

›Perianal abscess

›Fluctuance or focal induration

›Fistula

›External opening or drainage

›Dermatologic disease

›Perianal dermatitis, psoriasis, lichen sclerosus pattern

›Mass lesion

›Induration, ulcerated lesion, nonhealing wound

PITFALLS

›Common pitfalls

›Lateral fissure treated as primary fissure without evaluation for secondary causes

›Digital rectal exam attempted despite severe pain and sphincter spasm

04Differential Diagnosis/ddx29

Primary anorectal pain and bleeding

›Common alternatives

›Hemorrhoids

›Internal hemorrhoids with painless bleeding

›Thrombosed external hemorrhoid with acute pain

›Perianal abscess or fistula

›Deep ache, fever, drainage

›Proctitis

›Infectious proctitis

›Radiation proctitis

›Anal trauma

›Instrumentation-related injury

›Foreign body injury

Secondary fissure etiologies and serious mimics

›Serious and secondary causes

›Crohn disease with perianal involvement

›Multiple or lateral fissures

›Fistula or abscess

›Sexually transmitted infections

›HSV

›Syphilis

›Gonorrhea or chlamydia proctitis

›Malignancy

›Anal squamous cell carcinoma

›Dermatologic inflammatory disease

›Lichen sclerosus

›Contact dermatitis

›Coding aligned list

05Laboratory Tests/lt27

Labs for complications and alternatives

›Laboratory triage

›No routine labs for classic uncomplicated fissure

›Typical posterior midline fissure with minimal bleeding

›Complete blood count for significant bleeding concern

›Symptomatic anemia concern

›Persistent moderate bleeding

›C-reactive protein for inflammatory concern

›Suspected IBD flare features

›Suspected deep infection features

›Basic metabolic panel for dehydration or renal risk

›Significant diarrhea

›Poor oral intake

Infectious and secondary cause testing

›Targeted testing

›Pregnancy test when relevant

›Medication safety planning

›STI testing when risk or proctitis features

›NAAT for gonorrhea and chlamydia

›Syphilis serology

›HSV testing if vesicles or ulcers

›HIV testing when indicated

›Immunosuppression concern

›High-risk exposure history

Interpretation and limitations

›Result use

›Normal labs do not exclude perianal abscess

›Clinical exam remains primary

06Diagnostic Tests/dt34

Scoring Systems

›Symptom and bowel pattern tools

›Pain scale

›Baseline pain score for response tracking

›Post-defecation pain duration tracking

›Bristol Stool Form Scale

›Type 1 to 2 supports constipation contribution

›Type 6 to 7 supports diarrhea contribution

›Constipation severity history

›Straining frequency

›Incomplete evacuation sensation

MRI

›MRI pelvis indications

›Suspected complex perianal disease

›Recurrent abscess

›Suspected fistula

›Suspected Crohn perianal involvement

›Multiple or lateral fissures

›Chronic drainage

›Concern for malignancy extent

›Indurated lesion

CT

›CT abdomen and pelvis indications

›Suspected deep pelvic sepsis

›Systemic toxicity

›Severe pain out of proportion

›Suspected perirectal abscess not defined on exam

›Deep rectal pain

07Disposition/dispo26

ED and outpatient pathways

›Disposition decisions

›Discharge appropriate

›Typical fissure appearance

›Minimal bleeding

›Pain controlled with topical and oral options

›Able to tolerate oral intake and bowel regimen

›Urgent colorectal surgery follow-up

›Symptoms beyond 6 weeks

›Recurrent fissure pattern

›Failure of first-line therapy after 6 to 8 weeks

›Same-day surgical evaluation

›Suspected abscess

›Concern for necrotizing infection

›Concern for malignancy on exam

›Admission consideration

›Sepsis physiology

›Uncontrolled pain requiring parenteral analgesia

›Significant bleeding with symptomatic anemia concern

Follow-up timing

›Follow-up targets

›Primary care follow-up within 1 to 2 weeks

›Stool regimen adherence check

›Symptom improvement review

›Colorectal surgery follow-up within 2 to 6 weeks

›Chronic fissure features

›Atypical fissure location

›Second-line therapy planning

08Treatment/t56

First-line conservative care

›Core regimen

›Fiber supplementation

›Psyllium or equivalent daily

›Titrate to soft formed stool

›Osmotic stool softener

›Polyethylene glycol 17 g daily

›Titrate to 1 soft stool daily

›Sitz baths

›Warm water 10 to 15 minutes after bowel movement

›Additional 1 to 2 times daily for spasm relief

›Topical anesthetic

›Lidocaine 2% to 5% topical before bowel movement

›Short course to reduce discomfort and enable defecation

›Avoidance targets

›Straining

›Prolonged time on toilet

›Constipating medications when feasible

Topical sphincter relaxation therapy

›Nitric oxide donor option

›Glyceryl trinitrate ointment 0.2% to 0.4%

›Small amount to anal verge twice daily

›Duration up to 6 to 8 weeks

›Adverse effects headache and hypotension risk

›Contraindication concurrent PDE-5 inhibitor use

›Calcium channel blocker option

›Diltiazem 2% topical

›Small amount to affected area twice daily

09Special Populations/sp27

Pregnancy

›Pregnancy considerations

›Constipation prevention emphasized

›Fiber and osmotic stool softener favored

›Hydration and activity as tolerated

›Medication safety planning

›Prefer conservative regimen first

›Topical therapies used with obstetric awareness when needed

›Postpartum context

›Perineal trauma and constipation common triggers

›Early stool softening to prevent recurrence

Geriatric

›Older adult considerations

›Secondary cause vigilance

›Malignancy concern with atypical lesion

›Chronic ulceration requiring evaluation

›Higher dehydration and renal risk

›Stool softener titration with electrolyte monitoring when indicated

›Incontinence risk baseline assessment

›Prior obstetric injury

›Prior anorectal surgery

›Neurologic disease

Pediatrics

›Pediatric considerations

›Constipation as dominant driver

›Behavioral toileting plan

›Osmotic laxative weight-based per pediatric protocol

›Safeguarding considerations when indicated

10Background/b27

Epidemiology

›Frequency and context

›Common benign anorectal condition

›Often associated with constipation or diarrhea

›Typical location

›Posterior midline most common

›Anterior midline more common in women and pregnancy context

Pathophysiology

›Mechanism

›Linear tear in anoderm

›Trauma from hard stool or frequent stooling

›Internal anal sphincter spasm

›Reduced anodermal perfusion

›Impaired healing cycle

›Chronic fissure changes

›Sentinel skin tag

›Fibrosis and exposed sphincter fibers

Therapeutic Considerations

›Rationale for therapies

›Stool softening and fiber

›Reduce recurrent mechanical trauma

›Warm sitz baths

›Reduce sphincter spasm and pain perception

›Topical vasodilators and calcium channel blockers

›Lower resting sphincter pressure

›Improve local blood flow to promote healing

›Botulinum toxin

›Chemical sphincter relaxation

11Patient Discharge Instructions/pdi19

copy discharge instructions

›Discharge text

›Diagnosis anal fissure

›Goal soft stool daily without straining

›Fiber supplement daily with water

›Polyethylene glycol daily until stool soft then adjust dose

›Warm sitz baths 10 to 15 minutes after bowel movements and 1 to 2 more times daily

›Topical lidocaine before bowel movements as needed for pain

›If prescribed topical diltiazem or glyceryl trinitrate, apply small amount twice daily for up to 6 to 8 weeks

›Headache or dizziness possible with glyceryl trinitrate

›Avoid prolonged sitting on toilet and avoid straining

›Follow-up with primary care in 1 to 2 weeks

›Colorectal surgery follow-up if symptoms not improving within 2 to 4 weeks or if symptoms persist beyond 6 weeks

›Return to ED immediately

›Fever

›Worsening perineal pain or swelling

›Pus or new drainage

›Large or persistent rectal bleeding

›Lightheadedness or fainting

›New anal mass or rapidly worsening pain

12References/r7

Guidelines and evidence

›Key sources

›ASCRS Clinical Practice Guidelines for the Management of Anal Fissures 2023

›ASCRS Toolkit Management of Anal Fissures updated content

›NICE evidence summary for unlicensed 2% topical diltiazem for chronic anal fissure

›StatPearls Anal Fissures overview and adverse effects

›WHO ICD-10 browse K60 fissure and fistula of anal and rectal regions

›ICD-10-CM K60.0 K60.1 K60.2 code definitions

Evidence & Review

Evidence & Review