Name of the Condition

• Acute Anal Fissure
• Medical term: Anal fissure, acute

Summary

An acute anal fissure is a small tear in the lining of the anus, often causing pain and bleeding during bowel movements. It is typically a short-term condition that can heal with appropriate care and lifestyle adjustments.

Causes

• Straining during bowel movements
• Passing hard or large stools
• Chronic diarrhea
• Childbirth

Risk Factors

• Constipation or irregular bowel habits
• History of anal fissures
• Childbirth, particularly vaginal deliveries
• Underlying conditions like Crohn's disease

Symptoms

• Sharp pain during bowel movements
• Bright red blood on toilet paper or stool
• A visible crack or tear in the anal skin
• Itchiness or irritation around the anus

Diagnosis

• Physical examination of the anal region
• Medical history review
• Anoscopy, if needed, to examine the anus and rectum

Treatment Options

• Topical anesthetics to reduce pain
• Stool softeners to ease bowel movements
• Nitroglycerin ointments or calcium channel blockers to promote healing by relaxing the anal sphincter
• Increased fiber intake and hydration
• In severe or persistent cases, surgical options like lateral internal sphincterotomy

Prognosis and Follow-Up

• Most acute anal fissures heal within a few weeks with proper care.
• Regular follow-up may be needed to ensure healing and prevent recurrence.
• Maintaining soft bowel movements is key to preventing future fissures.

Complications

• Chronic anal fissure if left untreated
• Recurrence or persistence requiring surgical intervention
• Secondary infection of the fissure

Lifestyle & Prevention

• High-fiber diet to maintain regular, soft stools
• Staying hydrated to prevent constipation
• Avoiding prolonged sitting and straining during bowel movements

When to Seek Professional Help

• Severe or persistent pain that does not improve with self-care measures
• Significant bleeding from the anus
• Signs of infection, such as fever or swelling around the anal area

Additional Resources

• American Society of Colon and Rectal Surgeons (ASCRS)
• National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)
• Patient support groups for individuals with anal and colorectal health issues

Tips for Medical Coders

• Ensure specificity by noting whether the anal fissure is acute (K60.0) or chronic (K60.1).
• Verify documentation specifies the nature and duration of the fissure to avoid misclassification.
• Be attentive to differentiating primary fissure coding from those related to underlying conditions like Crohn's disease.