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.

Treatment & Management

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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.

of 2

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.