Bleeding and protrusion are among the most common symptoms of hemorrhoids. However, Mazier reported on a series of 500 patients with complaints of “hemorrhoids” and found that only one third had any significant hemorrhoids (personal communication). hemorrhoids bleeding typically results in bright red blood that drops into the toilet or is noted on the toilet. It is generally painless. More vigorous bleeding can occur as the hemorrhoids enlarge. Usually, prompt reduction of the protruding mass will cause this bleeding to abate. Acute thromboses of internal or external hemorrhoids are usually associated with severe pain that occurs with a palpable perianal mass. These patients are generally very uncomfortable, and the diagnosis is immediately obvious on clinical examination.
Examination of the patient with hematochezia, although dictated largely by the age of the patient, should include sufficient investigations to rule out a proximal source of bleeding, such as inflammatory bowel disease or neoplasia. Moreover, hemorrhoids bleeding is rarely a cause of iron-deficiency anemia.
The patient is examined in the left lateral position (or in the “head-down” position on the proctoscopy table) with the knees drawn up toward the chest as high as possible. This approach allows relative patient comfort and the ability to clearly inspect the perianal skin and to perform anoscopy and proctosigmoidoscopy. A careful digital examination of the anal canal and distal rectum should be performed, and the prostate should also be examined in male patients. An anoscope is essential to clearly inspect the hemorrhoidsal tissue and anal canal. The three common locations for hemorrhoids should be inspected, and the size, friability, and ease of prolapse of these areas should be recorded. After this, the decision regarding the need for more proximal colorectal evaluation should be considered, although rigid proctoscopy is a minimum. It cannot be emphasized enough that the examination must also be performed while the patient is seated on the toilet. The patient is asked to strain. Prolapsing hemorrhoidsal tissue in then sought. If none is found, but blood is present on the anal verge or examining finger, the patient has stage I disease. If the tissue prolapses, but reduces when the patient stops straining, the patient has stage II disease. If the prolapse must be reduced by the patient, it is stage III disease. Stage IV disease is obvious: an edematous nonreducing mass of internal and external hemorrhoidsal tissue is present at the anal verge. After the hemorrhoids are appropriately staged, treatment options should be explored.
