A 34-year-old man presents with an anal fissure located in the anterolateral position, far from the midline, which has failed conservative treatment. What is the most appropriate next step?
- A Proceed directly to lateral internal sphincterotomy
- B Biopsy the fissure edge and evaluate for Crohn's disease and other underlying disease ✓
- C Prescribe topical glyceryl trinitrate alone for six weeks
- D Perform anal dilatation under anaesthesia
Correct answer: B. Biopsy the fissure edge and evaluate for Crohn's disease and other underlying disease
Explanation
About 90 percent of idiopathic anal fissures occur in the posterior midline and most of the rest are anterior midline. A fissure away from the midline is atypical and should raise suspicion of a specific cause, classically Crohn's disease, but also HIV, tuberculosis, syphilis and malignancy. Biopsy and systemic evaluation are required before any sphincter-cutting surgery. Manual dilatation is abandoned because it causes sphincter disruption 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.