5/11/2015

HemorrhoidsClinicalPresentation:History,PhysicalExamination,GradingofInternalHemorrhoids

HemorrhoidsClinicalPresentation
Author:ScottCThornton,MDChiefEditor:JohnGeibel,MD,DSc,MSc,MAmore...
Updated:Nov03,2014

History
Mostlaypersonsandmanypractitionersattributeallperianalsymptomsto
hemorrhoids.Theastutecliniciancanoftenlistentoapatient'sdescriptionof
symptomsandascertainthesourceoftheproblemorconditionbeforeconfirmatory
examination.Nonhemorrhoidalcausesofsymptoms(eg,fissure,abscess,fistula,
pruritusani,condylomata,andviralorbacterialskininfection)needtobeexcluded.
Themostcommonpresentationofhemorrhoidsisrectalbleeding,pain,pruritus,or
prolapse.Becausethesesymptomsareextremelynonspecificandmaybeseenina
numberofanorectaldiseases,thephysicianmustthereforerelyonathorough
historytohelpnarrowthedifferentialdiagnosisandmustperformanadequate
physicalexamination(includinganoscopywhenindicated)toconfirmthediagnosis.
Familialpredisposition,diet,ahistoryofconstipationordiarrhea,andahistoryof
prolongedsittingorheavyliftingarealsorelevant,asareweightloss,abdominal
pain,oranychangeinappetiteorbowelhabits.Thepresenceofpruritusorany
dischargeshouldalsobenoted.
Inflammatoryboweldiseases(eg,ulcerativecolitis,Crohndisease)needtoberuled
outasthecauseofsymptoms.Humanimmunodeficiencyvirus(HIV)infectionand
otherimmunosuppressivediseasescanalsoaltertreatmentplans.

Symptoms
Anadequatehistoryshouldincludetheonsetanddurationofsymptoms.Inaddition
tocharacterizinganypain,bleeding,protrusion,orchangeinbowelhabits,special
attentionshouldbeplacedonthepatient'scoagulationhistoryandimmunestatus.
Rectalbleedingisthemostcommonpresentingsymptom.Thebloodisusually
brightredandmaydrip,squirtintothetoiletbowl,orappearasstreaksonthetoilet
paper.Thephysicianshouldinquireaboutthequantity,color,andtimingofany
rectalbleeding.Darkerbloodorbloodmixedwithstoolshouldraisesuspicionofa
moreproximalcauseofbleeding.
Apatientwithathrombosedexternalhemorrhoidmaypresentwithcomplaintsofan
acutelypainfulmassattherectum(seetheimagebelow).Paintrulycausedby
hemorrhoidsusuallyarisesonlywithacutethrombusformation.Thispainpeaksat
4872hoursandbeginstodeclinebythefourthdayasthethrombusorganizes.
Newonsetanalpainintheabsenceofathrombosedhemorrhoidshouldprompt
investigationforanalternatecause,suchasanintersphinctericabscessoranal
fissure.Asmanyas20%ofpatientswithhemorrhoidswillhaveconcomitantanal
fissures.

Thrombosedhemorrhoid.Thishemorrhoidwastreatedbyincisionandremovalofclot.

Thepresence,timing,andreducibilityofprolapse,whenpresent,willhelpclassify
thegradeofinternalhemorrhoidsandguidethetherapeuticapproach(seeGrading
ofInternalHemorrhoids).GradeIinternalhemorrhoidsareusuallyasymptomatic
but,attimes,maycauseminimalbleeding.GradesII,III,orIVinternal
hemorrhoidsusuallypresentwithpainlessbleedingbutalsomaypresentwith
complaintsofadullachingpain,pruritus,orothersymptomsduetoprolapse.

PhysicalExamination
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HemorrhoidsClinicalPresentation:History,PhysicalExamination,GradingofInternalHemorrhoids

Inadditiontothegeneralphysicalexamination,physiciansshouldalsoperform
visualinspectionoftherectum,digitalrectalexamination,andanoscopyor
proctosigmoidoscopywhenappropriate.
Thepreferredpositionforthedigitalrectalexaminationistheleftlateraldecubitus
withthepatient'skneesflexedtowardthechest.Topicalanesthetics(eg,20%
benzocaineor5%lidocaineointment)mayhelptoreduceanydiscomfortcausedby
examination.
Inspectandexaminetheentireperianalarea.Warnthepatientbeforeanyprobing
orpoking.Becausepatientapprehensionisgreatbeforeanyanalexamination,go
togreatlengthstoreassurethepatient.Gentlespreadingofthebuttocksallows
easyvisualizationofmostoftheanodermthisincludesthedistalanalcanal.Anal
fissuresandperianaldermatitis(pruritusani)areeasilyvisiblewithoutinternal
probing.Notethelocationandsizeofskintagsandthepresenceofthromboses.
Normalcorrugationoftheanodermandanormalanalwinkwithstimulation
confirmsintactsensation.
Thefollowingareexternalfindingsthatareimportanttonote:
Redundanttissue
Skintagsfromoldthrombosedexternalhemorrhoids
Fissures
Fistulas
Signsofinfectionorabscessformation
Rectalorhemorrhoidalprolapse,appearingasabluish,tenderperianalmass
Digitalexaminationoftheanalcanalcanidentifyanyinduratedorulceratedareas.
Alsoassessforanymasses,tenderness,mucoiddischargeorblood,andrectal
tone.Besuretopalpatetheprostateinallmen.Becauseinternalhemorrhoidsare
softvascularstructures,theyareusuallynotpalpableunlessthrombosed.
Currentguidelinesfrommostgastrointestinalandsurgicalsocietiesadvocate
anoscopyand/orflexiblesigmoidoscopytoevaluateanybrightredrectalbleeding.
Colonoscopyshouldbeconsideredintheevaluationofanyrectalbleedingthatis
nottypicalofhemorrhoidssuchasinthepresenceofstrongriskfactorsforcolonic
malignancyorinthesettingofrectalbleedingwithanegativeanorectal
examination.

GradingofInternalHemorrhoids
MostcliniciansusethegradingsystemproposedbyBanovetalin1985,which
classifiesinternalhemorrhoidsbytheirdegreeofprolapseintotheanalcanal.This
systembothcorrelateswithsymptomsandguidestherapeuticapproaches,as
follows.
GradeIhemorrhoidsprojectintotheanalcanalandoftenbleedbutdonot
prolapse
GradeIIhemorrhoidsmayprotrudebeyondtheanalvergewithstrainingor
defecatingbutreducespontaneouslywhenstrainingceases(ie,returnto
theirrestingpointbythemselves)
GradeIIIhemorrhoidsprotrudespontaneouslyorwithstrainingandrequire
manualreduction(ie,requiremanualeffortforreplacementintotheanal
canal)
GradeIVhemorrhoidschronicallyprolapseandcannotbereducedthese
lesionsusuallycontainbothinternalandexternalcomponentsandmay
presentwithacutethrombosisorstrangulation
DifferentialDiagnoses

ContributorInformationandDisclosures
Author
ScottCThornton,MDAssociateClinicalProfessorofSurgery,YaleUniversitySchoolofMedicineDirector,
ColorectalTeaching,BridgeportHospitalPrivatePractice,ParkAvenueSurgicalAssociates
ScottCThornton,MDisamemberofthefollowingmedicalsocieties:AmericanSocietyofColonandRectal
Surgeons
Disclosure:Nothingtodisclose.
Coauthor(s)
AdamJRosh,MDAssistantProfessor,ProgramDirector,EmergencyMedicineResidency,Departmentof
EmergencyMedicine,DetroitReceivingHospital,WayneStateUniversitySchoolofMedicine
AdamJRosh,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine,
AmericanCollegeofEmergencyPhysicians,SocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
KyleRPerry,MDResidentPhysician,DepartmentofEmergencyMedicine,DetroitReceivingHospital
KyleRPerry,MDisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,MichiganState
MedicalSociety,EmergencyMedicineResidents&#039Association
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard

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HemorrhoidsClinicalPresentation:History,PhysicalExamination,GradingofInternalHemorrhoids

FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
WilliamGGossman,MDAssociateClinicalProfessorofEmergencyMedicine,CreightonUniversitySchoolof
MedicineConsultingStaff,DepartmentofEmergencyMedicine,CreightonUniversityMedicalCenter
WilliamGGossman,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine
Disclosure:Nothingtodisclose.
ChiefEditor
JohnGeibel,MD,DSc,MSc,MAViceChairandProfessor,DepartmentofSurgery,SectionofGastrointestinal
Medicine,andDepartmentofCellularandMolecularPhysiology,YaleUniversitySchoolofMedicineDirector,
SurgicalResearch,DepartmentofSurgery,YaleNewHavenHospitalAmericanGastroenterologicalAssociation
Fellow
JohnGeibel,MD,DSc,MSc,MAisamemberofthefollowingmedicalsocieties:AmericanGastroenterological
Association,AmericanPhysiologicalSociety,AmericanSocietyofNephrology,AssociationforAcademic
Surgery,InternationalSocietyofNephrology,NewYorkAcademyofSciences,SocietyforSurgeryofthe
AlimentaryTract
Disclosure:ReceivedroyaltyfromAMGENforconsultingReceivedownershipinterestfromArdelyxfor
consulting.
AdditionalContributors
BrianJDaley,MD,MBA,FACS,FCCP,CNSCProfessorandProgramDirector,DepartmentofSurgery,Chief,
DivisionofTraumaandCriticalCare,UniversityofTennesseeHealthScienceCenterCollegeofMedicine
BrianJDaley,MD,MBA,FACS,FCCP,CNSCisamemberofthefollowingmedicalsocieties:American
AssociationfortheSurgeryofTrauma,EasternAssociationfortheSurgeryofTrauma,SouthernSurgical
Association,AmericanCollegeofChestPhysicians,AmericanCollegeofSurgeons,AmericanMedical
Association,AssociationforAcademicSurgery,AssociationforSurgicalEducation,ShockSociety,Societyof
CriticalCareMedicine,SoutheasternSurgicalCongress,TennesseeMedicalAssociation
Disclosure:Nothingtodisclose.
Acknowledgements
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgethecontributionsofpreviousauthors
DavidRGurley,MD,RichardSinert,DO,andPilarGuerrero,MD,tothedevelopmentandwritingofasource
article.

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