Diagnostic Considerations

Cardinal signs of internal hemorrhoids are painless bleeding and intermittent protrusion.^[17]The diagnosis generally requires exclusion of other conditions with similar symptoms.

Hemorrhoidal complaints are usually not associated with other medical conditions or diseases. However, patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:

Inflammatory bowel disease (IBD): IBD and hemorrhoidal problems occur frequently; unusual hemorrhoidal presentations and findings should alert the clinician to the potential of IBD.^[13]
Ulcerative colitis and Crohn disease
Pregnancy

Thrombosis of external hemorrhoids may result from clot formation in a vein under the squamous epithelium of the anal verge.

Varicosities caused from portal hypertension are a distinct entity from hemorrhoids.

Other conditions that should be considered when evaluating a patient with suspected hemorrhoids include anal cancer, anal fissures, and anal fistulae; pedunculated polyps; perianal abscesses; pruritus ani; prostatitis; proctitis, rectal prolase, proctalagia fugax; skin tags; condyloma; inflammatory bowel disease; and colorectal tumors.^[18]

Differential Diagnoses

Workup

Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 6th ed. Philadelphia, Pa: Elsevier; 2006. 1509-12.
Tintinalli JE, Kelen GD, Stapczynski JS, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw Hill; 2004. 540-1.
Ibrahim AM, Hackford AW, Lee YM, Cave DR. Hemorrhoids can be a source of obscure gastrointestinal bleeding that requires transfusion: report of five patients. Dis Colon Rectum. 2008 Aug. 51(8):1292-4. [QxMD MEDLINE Link].
Grucela A, Salinas H, Khaitov S, Steinhagen RM, Gorfine SR, Chessin DB. Prospective analysis of clinician accuracy in the diagnosis of benign anal pathology: comparison across specialties and years of experience. Dis Colon Rectum. 2010 Jan. 53(1):47-52. [QxMD MEDLINE Link].
Gibbons CP, Bannister JJ, Read NW. Role of constipation and anal hypertonia in the pathogenesis of haemorrhoids. Br J Surg. 1988 Jul. 75(7):656-60. [QxMD MEDLINE Link].
Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990 Feb. 98(2):380-6. [QxMD MEDLINE Link].
Johanson JF, Sonnenberg A. Constipation is not a risk factor for hemorrhoids: a case-control study of potential etiological agents. Am J Gastroenterol. 1994 Nov. 89(11):1981-6. [QxMD MEDLINE Link].
Bernstein WC. What are hemorrhoids and what is their relationship to the portal venous system?. Dis Colon Rectum. 1983 Dec. 26(12):829-34. [QxMD MEDLINE Link].
Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet. 1989 Feb 18. 1(8634):349-52. [QxMD MEDLINE Link].
Johansen K, Bardin J, Orloff MJ. Massive bleeding from hemorrhoidal varices in portal hypertension. JAMA. 1980 Nov 7. 244(18):2084-5. [QxMD MEDLINE Link].
Chawla Y, Dilawari JB. Anorectal varices--their frequency in cirrhotic and non-cirrhotic portal hypertension. Gut. 1991 Mar. 32(3):309-11. [QxMD MEDLINE Link]. [Full Text].
Katz JA, Rubin RA, Cope C, Holland G, Brass CA. Recurrent bleeding from anorectal varices: successful treatment with a transjugular intrahepatic portosystemic shunt. Am J Gastroenterol. 1993 Jul. 88(7):1104-7. [QxMD MEDLINE Link].
D'Ugo S, Stasi E, Gaspari AL, Sileri P. Hemorrhoids and anal fissures in inflammatory bowel disease. Minerva Gastroenterol Dietol. 2015 Dec. 61(4):223-33. [QxMD MEDLINE Link].
[Guideline] Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018 Mar. 61(3):284-92. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Rubbini M, Ascanelli S. Classification and guidelines of hemorrhoidal disease: present and future. World J Gastrointest Surg. 2019 Mar 27. 11(3):117-21. [QxMD MEDLINE Link]. [Full Text].
Rubbini M, Ascanelli S, Fabbian F. Hemorrhoidal disease: is it time for a new classification?. Int J Colorectal Dis. 2018 Jun. 33(6):831-3. [QxMD MEDLINE Link].
[Guideline] Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1. 116(10):1987-2008. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Mott T, Latimer K, Edwards C. Hemorrhoids: diagnosis and treatment options. Am Fam Physician. 2018 Feb 1. 97(3):172-9. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Tarasconi A, Perrone G, Davies J, et al. Anorectal emergencies: WSES-AAST guidelines. World J Emerg Surg. 2021 Sep 16. 16(1):48. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Wolf AMD, Fontham ETH, Church TR, et al. Colorectal cancer screening for average-risk adults: 2018 guideline update from the American Cancer Society. CA Cancer J Clin. 2018 Jul. 68(4):250-81. [QxMD MEDLINE Link]. [Full Text].
American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology. 2004 May. 126(5):1461-2. [QxMD MEDLINE Link].
[Guideline] Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011 Sep. 54(9):1059-64. [QxMD MEDLINE Link].
[Guideline] Wald A, Bharucha AE, Cosman BC, et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014 Aug. 109(8):1141-57; (Quiz) 1058. [QxMD MEDLINE Link]. [Full Text].
Chen HL, Woo XB, Cui J, et al. Ligasure versus stapled hemorrhoidectomy in the treatment of hemorrhoids: a meta-analysis of randomized control trials. Surg Laparosc Endosc Percutan Tech. 2014 Aug. 24(4):285-9. [QxMD MEDLINE Link].
El Nakeeb AM, Fikry AA, Omar WH, et al. Rubber band ligation for 750 cases of symptomatic hemorrhoids out of 2200 cases. World J Gastroenterol. 2008 Nov 14. 14(42):6525-30. [QxMD MEDLINE Link]. [Full Text].
Raahave D, Jepsen LV, Pedersen IK. Primary and repeated stapled hemorrhoidopexy for prolapsing hemorrhoids: follow-up to five years. Dis Colon Rectum. 2008 Mar. 51(3):334-41. [QxMD MEDLINE Link].
Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemorrhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum. 2007 Sep. 50(9):1297-305. [QxMD MEDLINE Link].
Ceci F, Picchio M, Palimento D, Cali B, Corelli S, Spaziani E. Long-term outcome of stapled hemorrhoidopexy for Grade III and Grade IV hemorrhoids. Dis Colon Rectum. 2008 Jul. 51(7):1107-12. [QxMD MEDLINE Link].
Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT. High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum. 1982 Jul-Aug. 25(5):454-6. [QxMD MEDLINE Link].
Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012 Aug 15. 8:CD004322. [QxMD MEDLINE Link].
Hollingshead JR, Phillips RK. Haemorrhoids: modern diagnosis and treatment. Postgrad Med J. 2016 Jan. 92(1083):4-8. [QxMD MEDLINE Link].
Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum. 1995 May. 38(5):453-6; discussion 456-7. [QxMD MEDLINE Link].
Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001 Mar. 44(3):405-9. [QxMD MEDLINE Link].
Yuksel BC, Armagan H, Berkem H, Yildiz Y, Ozel H, Hengirmen S. Conservative management of hemorrhoids: a comparison of venotonic flavonoid micronized purified flavonoid fraction (MPFF) and sclerotherapy. Surg Today. 2008. 38(2):123-9. [QxMD MEDLINE Link].
Faucheron JL, Gangner Y. Doppler-guided hemorrhoidal artery ligation for the treatment of symptomatic hemorrhoids: early and three-year follow-up results in 100 consecutive patients. Dis Colon Rectum. 2008 Jun. 51(6):945-9. [QxMD MEDLINE Link].
Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol. 1992 Nov. 87(11):1600-6. [QxMD MEDLINE Link].
Saleeby RG Jr, Rosen L, Stasik JJ, Riether RD, Sheets J, Khubchandani IT. Hemorrhoidectomy during pregnancy: risk or relief?. Dis Colon Rectum. 1991 Mar. 34(3):260-1. [QxMD MEDLINE Link].
Blaisdell PC. Prevention of massive hemorrhage secondary to hemorrhoidectomy. Surg Gynecol Obstet. 1958 Apr. 106(4):485-8. [QxMD MEDLINE Link].
Barron J. Office ligation treatment of hemorrhoids. Dis Colon Rectum. 1963 Mar-Apr. 6:109-13. [QxMD MEDLINE Link].
Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009 Aug. 104(8):2057-64. [QxMD MEDLINE Link].
Loh WL, Tan S, Ngooi MS, Ong ZK, Ngoi SS. Endoscopic monopolar coagulation of internal haemorrhoids: a surgeon's experience of the first 100 cases. Colorectal Dis. 2017 Jan. 19(1):O86-9. [QxMD MEDLINE Link].
Senapati A, Nicholls RJ. A randomised trial to compare the results of injection sclerotherapy with a bulk laxative alone in the treatment of bleeding haemorrhoids. Int J Colorectal Dis. 1988 Jun. 3(2):124-6. [QxMD MEDLINE Link].
Thornton SC. Sclerotherapy of hemorrhoids. Selected Topics in Colon and Rectal Surgery. Vol 5. Norwalk, Conn: Konsyl Pharmaceuticals; 1992:72-5.:
Gupta PJ, Kalaskar S. Radiowave ablation and mucopexy for prolapsing hemorrhoids--a pilot study. Int J Surg. 2009 Jun. 7(3):223-7. [QxMD MEDLINE Link].
Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015 Dec. 102(13):1603-18. [QxMD MEDLINE Link].
Leff EI. Hemorrhoidectomy--laser vs. nonlaser: outpatient surgical experience. Dis Colon Rectum. 1992 Aug. 35(8):743-6. [QxMD MEDLINE Link].
Corman M. Hemorrhoid. Corman M. Colon and Rectal Surgery. Philadelphia, Pa: Lippincott-Raven; 1998. 154-6.
Mazier WP. Hemorrhoids: surgery of the colon. Maxier WP, Levm DH, Luchtefeld. MA, Senagore AJ, eds. Rectum and Anus. Philadelphia, Pa: WB Saunders; 1995. 229-54.
Esser S, Khubchandani I, Rakhmanine M. Stapled hemorrhoidectomy with local anesthesia can be performed safely and cost-efficiently. Dis Colon Rectum. 2004 Jul. 47(7):1164-9. [QxMD MEDLINE Link].
Ho YH, Cheong WK, Tsang C, et al. Stapled hemorrhoidectomy--cost and effectiveness. Randomized, controlled trial including incontinence scoring, anorectal manometry, and endoanal ultrasound assessments at up to three months. Dis Colon Rectum. 2000 Dec. 43(12):1666-75. [QxMD MEDLINE Link].
Senagore AJ, Singer M, Abcarian H, et al. A prospective, randomized, controlled multicenter trial comparing stapled hemorrhoidopexy and Ferguson hemorrhoidectomy: perioperative and one-year results. Dis Colon Rectum. 2004 Nov. 47(11):1824-36. [QxMD MEDLINE Link].
Behboo R, Zanella S, Ruffolo C, Vafai M, Marino F, Scarpa M. Stapled haemorrhoidopexy: extent of tissue excision and clinical implications in the early postoperative period. Colorectal Dis. 2011 Jun. 13(6):697-702. [QxMD MEDLINE Link].
Pattana-arun J, Wesarachawit W, Tantiphlachiva K, Atithansakul P, Sahakitrungruang C, Rojanasakul A. A comparison of early postoperative results between urgent closed hemorrhoidectomy for prolapsed thrombosed hemorrhoids and elective closed hemorrhoidectomy. J Med Assoc Thai. 2009 Dec. 92(12):1610-5. [QxMD MEDLINE Link].
Bove A, Bongarzoni G, Palone G, Chiarini S, Calisesi EM, Corbellini L. Effective treatment of haemorrhoids: early complication and late results after 150 consecutive stapled haemorrhoidectomies. Ann Ital Chir. 2009 Jul-Aug. 80(4):299-303. [QxMD MEDLINE Link].
Ratto C, Parello A, Veronese E, et al. Doppler-guided transanal haemorrhoidal dearterialization for haemorrhoids: results from a multicentre trial. Colorectal Dis. 2015 Jan. 17(1):O10-9. [QxMD MEDLINE Link].
Bjelanovic Z, Draskovic M, Veljovic M, Lekovic I, Karanikolas M, Stamenkovic D. Transanal hemorrhoid dearterialization is a safe and effective outpatient procedure for the treatment of hemorrhoidal disease. Cir Esp. 2016 Dec. 94(10):588-94. [QxMD MEDLINE Link].
Scheyer M, Antonietti E, Rollinger G, Lancee S, Pokorny H. Hemorrhoidal artery ligation (HAL) and rectoanal repair (RAR): retrospective analysis of 408 patients in a single center. Tech Coloproctol. 2015 Jan. 19(1):5-9. [QxMD MEDLINE Link].
Perrotti P, Dominici P, Grossi E, Cerutti R, Antropoli C. Topical nifedipine with lidocaine ointment versus active control for pain after hemorrhoidectomy: results of a multicentre, prospective, randomized, double-blind study. Can J Surg. 2010 Feb. 53(1):17-24. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Russell MM, Ko CY. Management of hemorrhoids: mainstay of treatment remains diet modification and office-based procedures. National Guideline Clearinghouse. Available at http://guideline.gov/expert/expert-commentary.aspx?id=37828. Accessed: October 11, 2014.
Elbetti C, Giani I, Novelli E, Fucini C, Martellucci J. The single pile classification: a new tool for the classification of haemorrhoidal disease and the comparison of treatment results. Updates Surg. 2015 Dec. 67(4):421-6. [QxMD MEDLINE Link].
Vinson-Bonnet B, Higuero T, Faucheron JL, Senejoux A, Pigot F, Siproudhis L. Ambulatory haemorrhoidal surgery: systematic literature review and qualitative analysis. Int J Colorectal Dis. 2015 Apr. 30(4):437-45. [QxMD MEDLINE Link].
Milito G, Lisi G, Aronadio E, et al. LigasureTM hemorrhoidectomy: how we do. Minerva Gastroenterol Dietol. 2017 Mar. 63(1):44-9. [QxMD MEDLINE Link].
Crawshaw BP, Russ AJ, Ermlich BO, Delaney CP, Champagne BJ. Prospective case series of a novel minimally invasive bipolar coagulation system in the treatment of grade I and II internal hemorrhoids. Surg Innov. 2016 Dec. 23(6):581-5. [QxMD MEDLINE Link].
[Guideline] Yamana T. Japanese practice guidelines for anal disorders. I. Hemorrhoids. J Anus Rectum Colon. 2017. 1(3):89-99. [QxMD MEDLINE Link]. [Full Text].

Media Gallery

Hemorrhoids. Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.
Hemorrhoids. Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of a clot.

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Author

Kyle R Perry, MD Emergency Physician, The Queen's Medical Center; Volunteer Faculty, University of Hawaii, John A Burns School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF 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, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Scott C Thornton, MD Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Park Avenue Surgical Associates

Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors David R Gurley, MD, Richard Sinert, DO, and Pilar Guerrero, MD,to the development and writing of a source article.

Hemorrhoids Differential Diagnoses

Diagnostic Considerations

Differential Diagnoses

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