Anal Fissure Diagnosis and Presentation
Anatomical Relationship
- A sentinel skin tag is an associated physical finding that sits just distal to an anal fissure, with the fissure being a split in the squamous epithelium at or just inside the anal verge 1, 2, 3
- The sentinel tag represents a sign of chronicity in anal fissures, along with hypertrophied anal papilla at the proximal margin, fibrosis, and visualization of bare internal sphincter muscle at the fissure base 1, 2, 3
Clinical Presentation
- Bleeding from anal fissures is characteristically bright red and scanty, typically occurring during and after defecation 1, 2, 3
- The main symptoms include severe anal pain that occurs during and after defecation, with chronic fissure patients experiencing pain lasting many hours after bowel movements 1, 2, 3
Diagnostic Confirmation
- Fissures are best visualized by effacing the anal canal with opposing traction on the buttocks, allowing direct visualization of the split in the squamous epithelium 1, 2, 3
- The great majority of anal fissures occur in the midline, usually posteriorly 1, 2, 3
- If fissures occur off the midline, they mandate evaluation for underlying diagnoses such as Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer 1, 2, 3
Clinical Significance
- Up to 20% of patients with hemorrhoids have concomitant anal fissures, which can complicate the clinical picture 4, 5