If a midline fissure appears abnormal or fails to heal with conventional therapy, Crohn's disease should be suspected . Spontaneous healing is observed in
80% of patients with Crohn's fissures followed for 10 years . For this reason, the majority of the fissures may be treated medically. The Lahey Clinic found that only 15% of 56 patients with fissures required surgical treatment, despite 88% presenting with symptoms . A painful fissure is generally associated with an underlying abscess and may require an examination of the patient under general anaesthesia. If an abscess is found, simple drainage as described in the previous paragraph can provide relief without incontinence . If no abscess is found, medical management is appropriate, using local agents such as topical glyceryl nitrate or isosorbide dinitrate, nifedipine or symptomatic measures such as topical steroids or anaesthetic creams. In cases of persistent pain, the fissure may be treated as a classical anal fissure with careful internal sphinc-terotomy which may provide relief. The Ferguson Clinic reported healing without incontinence in 22 of 25 patients treated for anal fissure by internal sphinc-terotomy with a rectum free of disease and an anal fissure as presentation . In the Lahey Clinic experience, internal sphincterotomy was successful in 87% of patients without proximal disease, compared to a 42% healing rate if the proximal intestine was involved .Anal dilatation has not been successful and is discouraged as therapy. Some Crohn's ulcers may be large and acute with erosion into the sphincters compromising the continence. Intralesional injection of steroids may be effective if the ulcer is not too extensive. The natural evolution of these fissures and ulcerations result in strictures of the anal canal. Unfortunately, many of these patients will eventually require a proctectomy.
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