Diagnosis

Symptoms and Signs of Hemorrhoids

Bleeding: This is the most common symptom of hemorrhoids. It occurs when the sinusoidal vessels, which are thin-walled blood vessels in the hemorrhoidal cushions, rupture, tear, or ulcerate. The bleeding can be either spurting or oozing, depending on the size of the vessels involved. Small arterioles are associated with spurting, while tiny capillaries are associated with oozing. The bleeding is usually outward through the anal opening, but in rare cases, it may bleed upward into the rectum and colon and then return later as copious hematochezia, which is bright red blood in the stool. This can be confused with colonic bleeding, which has different causes and treatments ¹ ².
Protrusion: This is when the hemorrhoidal cushions slide down and protrude outside the anus, either spontaneously or when asked to strain. This happens due to congestion, elongation, and degeneration of the suspensory structures that hold the cushions in place. Protrusion can cause pain, irritation, and difficulty in cleaning the anal area ³.
Mucus discharge: This is when the hemorrhoidal cushions secrete excess mucus, which can leak out of the anus. This happens due to inflammation and trapping of the cushions between the sphincters. Mucus discharge can cause itching, burning, and infection.
Fecal soilage/incontinence: This is when the stool leaks out of the anus unintentionally. This happens due to impaired closure of the sphincter, which is the muscle that controls the opening and closing of the anus. Fecal soilage/incontinence can be caused by prolapsed or thrombosed hemorrhoids, anal stenosis, nerve damage, or aging.
Itching: This is a common symptom of hemorrhoids that causes discomfort and embarrassment. Itching can be caused by mucus and fecal soilage, which irritate the skin around the anus. It can also be caused by infection, inflammation, or allergic reaction to topical agents.
Tenesmus: This is a sensation of incomplete evacuation or a constant urge to defecate. Tenesmus can be caused by edema, congestion, swelling, and trapping of the hemorrhoidal cushions between the sphincters. Tenesmus can also be a sign of other conditions, such as inflammatory bowel disease, irritable bowel syndrome, or colorectal cancer.
Pain: This is a symptom of hemorrhoids that can range from mild to severe. Pain can be caused by stretching, incarceration, ischemia, and necrosis/ulceration of the hemorrhoidal cushions. Stretching occurs when the cushions are pulled down by gravity or straining. Incarceration occurs when the cushions are trapped outside the anus and cannot be pushed back in. Ischemia occurs when the blood supply to the cushions is cut off, causing tissue death. Necrosis/ulceration occurs when the cushions become infected or eroded by stool or bacteria.

Examination Findings

General and Systemic Examination

General and systemic examinations are often normal, except in anemic patients who may have pale skin and mucous membranes due to low hemoglobin levels¹.
Jaundice might be present in patients with chronic liver disease, which can cause yellowing of the skin and eyes due to high bilirubin levels².

Abdominal Examination

Specifically search for hepatomegaly or splenomegaly, which are enlarged liver and spleen, respectively. These might be present in portal hypertension, a condition where the blood pressure in the portal vein is increased due to liver cirrhosis or other causes³.
Note abdominal distension, which is swelling of the abdomen due to fluid accumulation, gas, or masses.
Note abdominal and pelvic masses, which are lumps or tumors that can be felt or seen in the abdomen or pelvis. These can be benign or malignant, and can have various causes, such as ovarian cysts, uterine fibroids, or colorectal cancer.

Digital Rectal Examination (DRE)

The goal of rectal examination is to view the perianal region, observe protrusion and bleeding, and palpate the mucosa and sphincter.
Inspection might show prolapsing hemorrhoids or anal tags. Prolapsing hemorrhoids are internal hemorrhoids that protrude outside the anus, either spontaneously or when asked to strain. Anal tags are remnants of skin that are left behind when external hemorrhoids heal.
Hemorrhoids are usually not palpable, except when thrombosed or fibrotic. Thrombosed hemorrhoids are external hemorrhoids that have a blood clot inside them, causing pain and swelling. Fibrotic hemorrhoids are internal hemorrhoids that have scarred and hardened due to chronic inflammation.
Although internal hemorrhoids cannot be palpated, digital examination will detect abnormal anorectal mass, anal stenosis, and scar. An abnormal anorectal mass is a lump or growth in the anus or rectum that can be benign or malignant, such as polyps, abscesses, or cancers. Anal stenosis is a narrowing of the anal canal due to scarring, inflammation, or surgery. Scar is a mark of healed tissue that can be seen or felt in the anus or rectum.
Digital examination will also evaluate anal sphincter tone, which is the strength and elasticity of the muscles that control the opening and closing of the anus. Anal sphincter tone can be normal, increased, or decreased, depending on the underlying condition. For example, anal fissures, which are small tears in the anal skin, can cause increased sphincter tone, while nerve damage or aging can cause decreased sphincter tone

Differentials

Rectal prolapse:
Prolapsed rectal polyps
Condylomata acumminata

Investigations for Hemorrhoids

Hemorrhoids are a clinical diagnosis and usually do not need intensive investigations. The history and examination with or without anoscopy commonly suffice. Anoscopy is particularly indicated as a clinic procedure in patients with first or second degree hemorrhoids where bleeding might be the most prominent symptom. However, specific investigations might include:

General Investigations

Complete blood count (CBC): This is a blood test that measures the number and quality of red blood cells, white blood cells, and platelets. It can help detect anemia, infection, or inflammation that may be related to hemorrhoids ¹.
Proctosigmoidoscopy/colonoscopy: These are procedures that use a flexible tube with a camera and light to examine the inside of the rectum and colon. They can help diagnose internal hemorrhoids, as well as rule out other causes of bleeding or pain, such as polyps, diverticula, or cancer ² ³.
Abdominal and pelvic ultrasound scanning: These are imaging tests that use sound waves to create pictures of the organs and structures in the abdomen and pelvis. They can help detect liver or spleen enlargement, abdominal or pelvic masses, or fluid accumulation that may be associated with portal hypertension or chronic liver disease, which are possible risk factors for hemorrhoids .

Indications for Colonoscopy

Colonoscopy is recommended for patients with hemorrhoids who have:

Other abdominal symptoms, especially if they are older than 50 years. These symptoms may include abdominal pain, weight loss, change in bowel habits, or blood in the stool.
Other findings at rectal examination and proctosigmoidoscopy, such as abnormal masses, ulcers, or strictures.
Family history of colorectal cancer or inflammatory bowel disease, which increase the risk of developing these conditions

Treatment Selection for Hemorrhoids:

Goal: Control symptoms and reduce progression, not necessarily a cure.

First Line (Conservative):

High fibre diet & liquids
Improved toilet habits
Sitz baths, ice packs, magnesium soaks
Analgesics
Oral medications: flavinoids (Daflon), calcium dobesilate, Glyceryl trinitrate, nifedipine (for specific cases)

Second Line (Minimally Invasive):

Considered after 1 month of aggressive first-line treatment fails, for grades 1-3.
Rubber band ligation: Most common, for internal hemorrhoids only. Simple, effective, outpatient.
Sclereotherapy: For grades 1-2 only. Injects chemicals to cause fibrosis and fix mucosa.
Coagulation methods: Infrared, radiofrequency ablation, cryotherapy (less common due to pain).
Hemorrhoidopexy: Stapler procedure to excise and resuspend hemorrhoids.

Third Line (Surgical):

For grade 4 or if minimally invasive fails.
Hemorrhoidectomy: Most effective, lowest recurrence rate. Various techniques exist.

Other points to note:

Treatment decision depends on grade, symptoms, previous treatment, and patient preference.
Multiple locations might require treatment in phases to avoid stenosis.

Procedures above the dentate line usually don’t require anesthesia.

HEMORRHOIDS III DIAGNOSIS & TREATMENT