On inspection the anal fissure is usually seen in the anal margin, situated in the midline posteriorly (6 o'clock). The fissure appears as an elliptical ulcer involving the lower third of the anus from the dentate line to the anal verge. 1

Digital examination and sigmoidoscopy are difficult because of painful anal sphincter spasm.

If there are multiple fissures Crohn's disease should be suspected. These fissures look different, being indurated, oedematous and bluish in colour.

In chronic anal fissures a sentinel pile is common and in long-standing cases a subcutaneous fistula is seen at the anal margin, with fibrosis and anal stenosis. 1

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