MSC - F. Surgery Answers 2025
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2.Anemia
Usually chronic due to repeated hemorrhoidal bleeding.
Treatment includes:
o Managing bleeding (e.g., sclerotherapy).
oIron supplementation and blood transfusions in severe cases.
3.Chronic Anal Fissure
Can develop as a secondary complication of hemorrhoids.
Surgical treatment often involves simultaneous excision of fissure and hemorrhoids.
4.Perianal Itch (Pruritus)
Secondary to hemorrhoids.
Resolves after effective treatment of hemorrhoids.
5.Paraproctitis
Rare complication of hemorrhoids.
May require synchronous surgery for hemorrhoids and associated rectal fistulas.
7. Acute anal fissure: Etiopathogenesis, clinic, diagnosis, treatment.
1.Etiology and Pathogenesis
Anal fissure is a tear or ulcer of the anal canal wall, usually 1–2 cm long, mostly at the posterior midline (6 o’clock).
Caused by mechanical trauma due to hard stools (constipation) or diarrhea.
Commonly associated with other anorectal diseases (proctitis, colitis, hemorrhoids).
In women, can occur during childbirth.
Neuro-reflex theory: pain causes internal sphincter spasm → ischemia → impaired healing → vicious cycle.
2.Clinical Presentation
Classic triad:
o Severe pain during/after defecation
o Bright red blood streaks on stool
oAnal sphincter spasm
Pain leads to fear of defecation, worsening constipation and fissure.
3.Diagnosis
Visual inspection reveals fissure, usually a linear or slit-like tear with soft edges in acute cases.
Digital rectal exam and proctosigmoidoscopy are done with local anesthesia (Novocain or spray) due to pain.
Chronic fissures show thick, fibrotic edges and sentinel piles (skin tags).
Must differentiate from:
oThrombosed hemorrhoids
o Coccygodynia
o Crohn’s disease
oAnal cancer/ulcers (syphilis, tuberculosis)
Biopsy if diagnosis unclear.
4. Treatment
Conservative for acute fissures (successful in ~70%): o Pain control
o Relieve sphincter spasm (topical nitrates, calcium channel blockers) o Treat constipation (fiber, fluids, stool softeners)
o Good hygiene
o Diet: mainly vegetarian, avoid spicy/salty food and alcohol o Use of healing ointments
Surgical for chronic fissures:
o Excision of fissure, scar tissue, and sentinel piles
o Often combined with lateral internal sphincterotomy to reduce spasm o Wound healing by secondary intention
o~94% cure rate
Important to also manage any underlying gastrointestinal diseases.
Bottom line: Acute anal fissures respond well to conservative care; chronic fissures require surgery. The main enemy is the painful sphincter spasm blocking healing — break that cycle and you win.
8. Chronic anal fissure: clinic, diagnosis, treatment.
Chronic Anal Fissure: Clinic, Diagnosis, Treatment
Clinical Presentation:
A chronic anal fissure is a tear in the anal canal, usually 1–2 cm, often located at the posterior midline (6 o’clock).
Common symptoms:
o Persistent severe pain during/after defecation
o Moderate bleeding (bright red blood streaks on stool)
o Anal sphincter spasm leading to a vicious cycle of pain and ischemia
Chronic fissures develop calloused, thickened edges with granulation tissue called sentinel piles (skin tags).
Diagnosis:
Simple visual inspection after parting the buttocks reveals the fissure.
Digital rectal exam and proctosigmoidoscopy are done with local anesthesia (Novocain or anesthetic spray) to reduce pain.
Chronic fissures differ from acute by their hard, fibrotic edges and sentinel piles.
Important to differentiate from:
o Thrombosed hemorrhoids
o Coccygodynia
o Crohn’s disease
oAnal cancer or ulcers (syphilis, tuberculosis)
If unclear, biopsy and further investigations are needed.
Treatment:
Conservative treatment is for acute fissures only, with about 70% success: pain control, reduce sphincter spasm, manage constipation, hygiene, and diet (avoid irritants).
Chronic fissures require surgery:
o Excision of the fissure, scar tissue, and sentinel piles
oFollowed by a controlled (dosaged) lateral internal sphincterotomy to relieve sphincter spasm
oThe wound heals by secondary intention (left open)
Surgical cure rate is high (~94%).
Managing any associated GI diseases is crucial for lasting success.
Bottom line: Chronic fissures don't heal on their own because the sphincter spasm starves the tissue of blood. Surgery cuts through the spasm and removes scar tissue, breaking the cycle and healing the fissure.
9. Differential diagnosis of acute and chronic anal fissure.
Feature
Duration
Pain
Bleeding
Physical Appearance
Tissue Consistency
Granulation tissue
Sentinel pile (external skin tag)
Hypertrophied anal papilla (internal)
Anal sphincter tone
Response to conservative therapy
Acute Anal Fissure |
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Chronic Anal Fissure |
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< 6 weeks |
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> 6 weeks |
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Sharp, intense during and |
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Persistent, possibly more |
shortly after defecation |
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tolerable, but longer-lasting |
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Bright red blood on stool |
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Recurrent minor bleeding, |
or toilet paper |
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blood streaks on stool |
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Fresh linear or slit-like tear 
Deep ulcer with thickened, indurated edges
Soft margins |
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Hard, fibrotic, scarred edges |
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Absent |
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Present (granulation at base |
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of fissure) |
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Absent |
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Often present |
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Absent |
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May be present |
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Increased tone (transient |
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Persistently elevated tone |
spasm) |
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Usually heals with |
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Rarely heals without |
conservative measures |
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surgical intervention |
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10. Treatment of acute and chronic anal fissure.
1. Acute Anal Fissure
Goal: Conservative treatment aiming for spontaneous healing (success rate up to 70%).
Conservative Management
First-line treatment for acute cases (≤ 6 weeks duration):
a.Dietary and Lifestyle Measures
High-fiber diet (vegetables, whole grains, fruits)
Increased fluid intake (2–3 L/day)
Avoidance of spicy, acidic foods, alcohol
Stool softeners (e.g., lactulose, polyethylene glycol)
Sitz baths (warm water soaks) 2–3 times/day
b.Local Pharmacologic Therapy
Topical anesthetics (e.g., lidocaine)
Topical vasodilators:
oNitroglycerin 0.2–0.4% ointment: reduces sphincter tone, improves perfusion
oCalcium channel blockers (e.g., diltiazem or nifedipine ointments): fewer side effects than nitrates
Anti-inflammatory agents: in some cases (e.g., topical hydrocortisone for pruritus)
c. Pain Control
NSAIDs (if tolerated)
Topical analgesic gels
2. Chronic Anal Fissure
Goal: Restore normal anatomy, relieve spasm, and promote re-epithelialization. Conservative therapy often fails; surgical treatment is frequently required.
Conservative Measures (Trial First)
Same as in acute fissure, but usually less effective. Try for 6–8 weeks:
Topical nitroglycerin or diltiazem
Stool softeners
Fiber supplementation
Warm sitz baths
Surgical Treatment (Mainstay in Chronic Cases)
Indicated when:
Fissure persists >6–8 weeks
Conservative therapy fails
Chronic fibrosis with sentinel pile or hypertrophied papilla
a.Lateral Internal Sphincterotomy (LIS)
Gold standard
Involves controlled division of internal anal sphincter
Reduces resting pressure and spasm
Healing in >90% of cases
Risk: minor incontinence (gas or staining in ~5–10%)
b.Fissurectomy
Excision of the fissure, fibrotic edges, and sentinel pile
May be combined with sphincterotomy
Leaves wound open for healing by secondary intention
c.Botulinum Toxin Injection
Useful for patients unwilling or unfit for surgery
Injected into internal sphincter
Temporary relaxation; healing in 60–80%
Recurrence common
Postoperative Care
Continued stool regulation
High-fiber diet
Personal hygiene
Sitz baths
Analgesics
11.Acute paraproctitis: definition, etiology, pathogenesis, classification.
Definition:
Acute paraproctitis is a purulent inflammatory process in the tissues surrounding the rectum (paraproctium), most commonly resulting in an anal abscess.
It is the 4th most common proctologic disease after hemorrhoids, anal fissure, and colitis.
Peak incidence: Adults aged 20–60 years
Sex: More common in males
Etiology:
Polymicrobial infection:
o Aerobes: Staphylococcus, Streptococcus, E. coli
oAnaerobes (rare): Bacteroides, Clostridia
Entry point: Infection of anal crypt glands
Risk factors:
oHard feces (trauma)
o Pre-existing proctologic diseases (fissures, hemorrhoids)
o Immunosuppression, diabetes
o Rarely: Hematogenous or lymphogenous spread
Pathogenesis:
1.Infection enters via crypts of Morgagni at the dentate line.
2.Spreads to adjacent spaces (intersphincteric, ischiorectal, etc.).
3.Leads to abscess formation in perirectal tissues.
4.If untreated → chronic paraproctitis (fistula formation)
Classification (Russian Federation’s Coloproctology Center):
1.By Etiology:
Nonspecific (common pyogenic)
Specific (e.g., TB, actinomycosis, syphilis)
Post-traumatic
2.By Inflammatory Activity:
Acute abscess
Relapsing paraproctitis
Chronic paraproctitis (fistula formation)
3.By Anatomical Location:
Subcutaneous (most superficial)
Submucous
Ischiorectal (deep lateral)
Pelviorectal (deep supralevator)
4.By Internal Fistulous Opening:
Anterior, Posterior, Lateral
5.By Fistulous Tract (Chronic):
Intersphincteric
Transsphincteric
Extrasphincteric
12. Acute paraproctitis: clinic, diagnosis and treatment.
Clinical Presentation:
Sudden onset, rapidly progressive
Severe, throbbing pain in perianal or perineal region
Fever, chills, malaise (systemic signs of sepsis)
Pain worsens with defecation or sitting
Redness, swelling, tenderness in the perianal region (if superficial)
Pelviorectal/ischiorectal abscess: deep-seated pain, rectal fullness, urinary difficulty (late signs)
Diagnosis:
History + Physical Examination
Perianal tenderness, fluctuation, erythema
Rectal Exam:
Avoid in severe pain; may need local anesthesia
May feel a deep boggy mass (ischiorectal or pelviorectal)
Imaging:
Ultrasound (TRUS) – accuracy ~86%
MRI – for deep pelvic abscesses or complex anatomy
CT – helpful in uncertain or recurrent cases