eMedicine Specialties > General Surgery > Colorectal

Hemorrhoids: Workup

Author: Scott C Thornton, MD, Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Colon and Rectal Surgeons
Contributor Information and Disclosures

Updated: Mar 3, 2009

Workup

Laboratory Studies

  • Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected.
  • Coagulation studies are indicated if the history and physical examination suggest coagulopathy.

Imaging Studies

  • Barium enema study or virtual colonoscopy is suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful.

Diagnostic Procedures

  • Examination begins with inspection and examination of the entire perianal area. Warn the patient before any probing or poking. Because patient apprehension is great prior to any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation. Digital examination of the anal canal can identify any indurated or ulcerated areas. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable.
  • Anoscopy is mandatory for viewing internal hemorrhoids. The anoscope should be a side-viewing one. When angled well by the examiner, the side-viewing anoscope allows the soft hemorrhoidal tufts to fill the beveled end of the scope and to be appropriately evaluated. Prolapse can be observed when the patient performs a Valsalva maneuver. Flexible sigmoidoscopy is performed to exclude proximal disease. Having a patient strain while sitting on a toilet may reproduce prolapse most accurately. Examining patients while they sit on a toilet can be very helpful in indeterminate cases. Colonoscopy, virtual colonoscopy, and barium enema are reserved for cases of bleeding without an identified anal source. These symptoms are not attributable to hemorrhoids and are considered to be non – outlet-type bleeding.

Histologic Findings

Routine histologic examination of hemorrhoidal tissue is usually unrewarding, especially if it is grossly examined by an experienced anorectal surgeon. Any suspicious tissue must be sent for microscopic evaluation. External hemorrhoids are classified by underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems.

Staging

Internal hemorrhoids are grouped into 4 stages, as follows: 

  • Stage I - Internal hemorrhoids that bleed 
  • Stage II – Internal hemorrhoids that cause bleeding and prolapse with straining but return to their resting point by themselves
  • Stage III - Internal hemorrhoids that bleed and prolapse with straining and require manual effort for replacement into the anal canal 
  • Stage IV - Internal hemorrhoids that do not return into the anal canal and are therefore constantly outside

More on Hemorrhoids

Overview: Hemorrhoids
Workup: Hemorrhoids
Treatment: Hemorrhoids
Follow-up: Hemorrhoids
References
Further Reading
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References

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Further Reading

Related eMedicine topics:
Constipation [Emergency Medicine]
Constipation [Gastroenterology]
Constipation [Pediatrics: General Medicine]
Constipation and Bowel Management
Crohn Disease [Gastroenterology]
Crohn Disease [Pediatrics: General Medicine]
Crohn Disease [Radiology]
Hemorrhoids [Emergency Medicine]
Inflammatory Bowel Disease [Emergency Medicine]
Inflammatory Bowel Disease [Gastroenterology]
Inflammatory Bowel Disease [Ophthalmology]
Portal Hypertension [Gastroenterology]
Portal Hypertension [Radiology]
Rectal Prolapse [Emergency Medicine]
Rectal Prolapse [General Surgery]
Rectal Prolapse [Pediatrics: General Medicine]
Rectal Prolapse: Surgical Perspective
Thrombosed External Hemorrhoid Excision
Ulcerative Colitis [Gastroenterology]
Ulcerative Colitis [Pediatrics: General Medicine]
Ulcerative Colitis [Radiology]

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Keywords

hemorrhoids, piles, hemorrhoid, external hemorrhoids, internal hemorrhoids, hemorrhoids treatment, external hemorrhoid, hemorrhoids surgery, hemorrhoidectomy, hemorrhoidal, hemorrhoids pregnancy, bleeding hemorrhoids, thrombosed hemorrhoids, hemorrhoids cure, hemorrhoids symptoms, hemorrhoids cause, hemorrhoids pain, internal hemorrhoid, inflammatory bowel disease, hemorrhoidal problems, anorectal problems, ulcerative colitis, Crohn disease, enlarged hemorrhoids, straining, constipation, anorectal varices, prolapsed internal hemorrhoids, rectal prolapse, perianal pain, pruritus ani

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Contributor Information and Disclosures

Author

Scott C Thornton, MD, Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Colon and Rectal Surgeons
Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Brian James Daley, MD, MBA, FACS, Associate Program Director, Professor, Department of Surgery, Division of Trauma and Critical Care, University of Tennessee School of Medicine
Brian James Daley, MD, MBA, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Eastern Association for the Surgery of Trauma, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, and Tennessee Medical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Michael A Grosso, MD, Consulting Staff, Department of Cardiothoracic Surgery, St Francis Hospital
Michael A Grosso, MD is a member of the following medical societies: American College of Surgeons, Society of Thoracic Surgeons, and Society of University Surgeons
Disclosure: Nothing to disclose.

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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