A 33-Year-Old Man Comes to the Office Due to Persistent

A 33-year-old man comes to the office due to persistent anal pain.  Two months ago, the patient experienced severe anal pain associated with bowel movements.  Evaluation revealed an anal fissure and external hemorrhoids for which he was treated with stool softeners and topical nitroglycerine.  His symptoms have persisted despite adherence with the medical therapy and high-fiber diet.  He reports no history of anal trauma or anal intercourse.
Vital signs are within normal limits.  Rectal examination is painful and reveals a posterior midline anal fissure, large skin tag, and external hemorrhoids with no thrombosis.  The remainder of the physical examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits.  Which of the following is the most appropriate next step in management of this patient's disorder?

A) Anal ulcer biopsy to rule out malignancy
B) Colonoscopy to rule out Crohn disease
C) Rapid plasma reagin test for syphilis
D) Rubber band ligation of the hemorrhoids
E) Serologic tests for celiac disease

Correct Answer:

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