Snap Shot A 45-year-old man has severe rectal pain when he defecates. He reports the stool is covered with bright red blood. A sentinel pile is noted on physical exam. Introduction Tear or fissure in anal epithelium mostly located on posterior or anterior anal vergre Due to irritating diarrhea hard stool disease process (Crohn's, CA, STD, UC, AIDS) Leads to tightening of anal canal related to nervous tension Presentation Symptoms severe rectal pain on defecation bleeding anal tenderness Evaluation Anoscopy sentinel pile (thickened mucosa) is found below the fissure hypertrophied papilla is noted above the fistula Treatment Conservative treatment stool softeners increased water intake topical hydrocortisone/anesthetic creams botox Lateral internal sphincterotomy (LIS) indicated if medical treatment ineffective