A 28-year-old woman presents with an anal fissure located in the anterolateral position at the 10 o'clock position. She also reports weight loss and intermittent diarrhoea. What does this atypical location suggest, and what is the appropriate next step?
- A Crohn's disease, evaluate with colonoscopy and MRI pelvis ✓
- B Chronic idiopathic constipation, treat with stool softeners alone
- C Anal squamous cell carcinoma, proceed directly to wide local excision
- D Internal sphincter hypertonia, perform lateral internal sphincterotomy immediately
Correct answer: A. Crohn's disease, evaluate with colonoscopy and MRI pelvis
Explanation
More than 90 percent of simple anal fissures occur in the posterior midline, with most of the remainder in the anterior midline. B fissure away from the midline, especially when multiple, painless, or accompanied by systemic features like weight loss and diarrhoea, strongly suggests underlying Crohn's disease. Management requires assessment of the extent of intestinal disease with colonoscopy and imaging before any local surgical intervention, since sphincterotomy in Crohn's disease carries a high risk of poor healing and incontinence.
Reference: Bailey and Love's Short Practice of Surgery, 27th ed.
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Written and medically reviewed by the StethoPrep medical team.