Anal fissure best choice SR Brown Colorectal Surgeon Sheffield Teaching Hospitals Overview • What we are taught in medical school • The evidence for non-surgical therapy • The evidence for surgery • Why do some treatments not work Acute fissure • Passage hard stool Acute fissure treatment • Diet • Analgesia Excoriation Treatment • Avoid soap • Barrier creams Crohn’s fissure • Atypical position • Associated disease – Fleshy tags – fistulae Nicorandil associated ulceration • Well circumscribed • Skin undermining • Cardiac cripples Definition of a chronic fissure • >6 week history • Wider and deeper than acute fissure (IAS fibres) • Midline • Skin tag Classic aetiology of a chronic fissure • High sphincter tone • Poor midline anal blood supply