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The purpose of this study was to investigate whether endoanal ultrasonographic findings could better characterize chronic anal fissures, mostly in those patients with persistent and recurrent disease after medical treatmentsBetween January 2004 and December 2009, patients referred to our Departments complaining anal pain and suspected for anal fissure were considered. Physical examination and anoscopy confirmed the diagnosis of anal fissure in 543 patients. Chronicity was defined on the basis of morphological features of the fissure and mainly on its persistence or recurrence after medical therapy.A total of 172 patients (95 males, mean age 41.2 years) fulfilled the inclusion criteria for chronic anal fissure and were included in thepresent study. In 112 (65.1%) of 172 patients submitted to endoanal ultrasonography an associated intersphincteric chronic abscess was demonstrated. Ninetyone (52.9%) were associated with intersphincteric and 21 (12.2%) with low transphincteric fistulas respectively.We suppose that chronic fissures may persist because of hidden sepsis in the anal canal and, in our belief, a further pathological cause should be considered before surgery in order to avoid this potential risk and treat fissure in aproper way. Chronic anal fissure might be the clinical and pathological expression of a coexisting intersphincteric or low transphincteric fistula.