The first thing to distinguish is whether it is a “hemorrhoid” or a “flap”. Patients with Crohn’s disease more commonly have a flap around the anus, which can sometimes be difficult to distinguish from a hemorrhoid, so you should see your doctor for a closer examination to determine whether it is a hemorrhoid or a flap. The size, shape, and nature of the flaps vary. Some are large, edematous, hard and purple, while others are like “elephant ears”, flat, with a wide or narrow base, soft and painless. The large dermatomes are often lesions left over from a healed fistula or fissure. Hemorrhoids are dilated masses of blood vessels and therefore are usually soft and painless. Hemorrhoids are often uncomfortable, but can become hard and painful when active as in Crohn’s disease; severe diarrhea caused by Crohn’s disease can cause symptoms, such as bleeding. If “hemorrhoids” are identified, medications include sitz baths, topical medications, and diarrhea control. Because surgical excision often leads to non-healing wounds, infection, anal stricture, and the possibility of anal sphincter damage, hemorrhoid surgery, including external peel and tie, PPH, and ligation, should generally be avoided. In the absence of any anorectal CD, surgical excision or ligation may also be performed in carefully selected patients.