<s>[INST] context: Fissure-in-Ano- Location of dentate line - usually 2cm below the anal verge.- Longitudinal split in the anoderm from anal verge to the dentate line- Location - In posterior midline at 6'o clock position - Fissure is of two types* Acute fissures* Chronic fissures - Chronic fissures - Characterized by Triad* CANOE- SHAPED ULCER* SENTINEL PILE (aka skin tag)* Hyperophied papilla Pathophysiology- Spasm of Internal Anal sphincter- Patients have constipation- During excessive straining at the time of defecation, the fecal matter passing throughinternal anal sphincter injures the pain sensitive mucosa of anal canal.Tear/ split in the anoderm |Decreased vascularity |Healing of Tear decreases (due to ischemia) - Principle of treatment is based on relaxing the spasm- Fissure in Ano is similar to Achalasia cardia Clinical features- Serve pain during defecation- Streaking of blood over stool- In fissure in Ano - Digital rectal examination is contraindicated.- Examine the gluteal region, find the longitudinal spilt in posterior midline Management- Initially conservative management* Sitz bath* Stool softener- Medical Treatment* CCB - 2% Diltiazem Gel - (Local application)* Nitrates - 0.2% nitroglycerine* Botox injection into sphincters* Lord's procedure - manual dilatation of sphincter (not performed usually).* TOC - NOTARA'S lateral sphincterotomy (divide internal anal sphincter laterally)* Anal advancement flap [/INST] question: Anal fissure best diagnosed by: | options: A: Anoscopy B: History and superficial clinic examination C: PR examination D: USG | answer: B </s>