Hemorrhoids Workup

Updated: May 31, 2022
  • Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Approach Considerations

Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.


Hematologic Tests

A complete blood cell (CBC) count may be useful as a marker for infection. Anemia due to hemorrhoidal bleeding is possible, [3] albeit rare (0.5 cases per 100,000 patients), and its presence should raise suspicion of an alternate diagnosis. Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected.

Coagulation studies are indicated if the history and physical examination suggest coagulopathy.


Anoscopy and Flexible Sigmoidoscopy

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; in addition, examining patients while they sit on a toilet can be very helpful in indeterminate cases.


Other Diagnostic Imaging Studies

Proctoscopy may be performed to supplement anoscopy, and proctography may be indicated in rectal prolapse.

In patients who are suspected of having complicated hemorrhoids, the World Society of Emergency Surgery and American Association for the Surgery of Trauma (WSES-AAST) guidelines suggest imaging investigation (CT scanning, MRI, or endoanal ultrasonography) only if there is suspicion of concomitant anorectal diseases (sepsis/abscess, inflammatory bowel disease, neoplasm). [19]

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

Full evaluation of the large bowel with colonoscopy is recommended for patients with significant abdominal symptoms, weight loss, change in bowel habits, or other risk factors for colonic malignancy. The American Cancer Society recommends that people of average risk of colorectal cancer start regular screening at age 45. [20]


Histologic Features

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 the underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems.