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Case 43: Rectal bleeding

A 32 year old man presents with pain and bright red rectal bleeding. He has seen the blood on the paper and has been constipated for the last 2 weeks.

1. What does the photo show?

A posterior midline anal fissure. From the short history - an acute fissure.

2. What are the management options?

Initially conservative. Attention to treating constipation or diarrhoea. Simple analgesia, stool softeners, bulking agents, patient advice. Then topical GTN paste.

3. What is the basis of pharmacologic treatment?

GTN paste is thought to act by causing relaxation of the internal sphincter muscle. The hypertonicity of the internal sphincter is thought to perpetuate the fissure by causing ischaemia therefore preventing healing. The spastic sphincter is also thought to explain the prolonged severe post defaecation pain theat these patients suffer.

GTN paste can cause headache if used to excess so the patients should be warned.