Anal Fissur, Primary Type vs. Anal Fissure, Secondary Type
Left picture: It is a primary anal fissure which is relatively frequent in infancy. Primary anal fissures also belong in the other age groups of childhood to the most frequent causes of passage of bright-red blood by the anus. Constipation is a major reason for their development, and the anal fissure itself may leed to constipation. In contrast to the secondary anal fissures which are due to Crohn´s disease or to immunosuppression or -deficiency, primary fissure are in 90% of the cases singular and localized on the posterior midline. In addition to melena, perianal pain is observed during each defecation and posssibly traces of bright-red blood on the stool (Double picture: New York Times Health www.nytimes.com, single picture: dkimages discover health and beauty www.dkimages.com). Right picture: The diagnosis is a secondary type of anal fissure in a boy with Crohn´s disease. This diagnosis is supported by the age of the patient (teenager), by properties of the stool, such as slightly diarrheal stool which is rarely bloody, by the local findings, such as irritation of the perianal region with traces of scratching, and the site, structure, and number of the fissures: Chronicity of the fissure with ulcer, and raised edges and cutaneous tag at its distal end; in additon, second fissure at 12 o´clock at the anterior commissure.
Left picture: Infant with passage of fresh bright-red blood by the anus. A defect is visible at the posterior commissure of the anus. The double picture shows on the left side a tear in the posterior midline and on the right side the close anatomical relation of the tear to the external and internal sphincter muscle. The additional picture shows how the tear involves the cutaneous part of the anal channel as well as the mucosa. Right picture: Local findings in a 13-year-old boy without and with spreading wide the buttocks, the latter being visible in the picture at the bottom. The boy complains of pain during defecation, and of fresh blood on the stool. At 6 o´clock a deep fissure is visible with a cutaneous tag at its peripheral end.