Hemorrhoids - Diagnosis and treatment (Part Two)

To examine a patient suspected of having hemorrhoids, it is necessary:

• The patient lies on the left side.
• The pathology is described using the clock reference system, where 12 o'clock is located at the front relative to the dentate line (the serrated line).

To see them, it is necessary that in addition to the digital examination, the patient must undergo a sigmoidoscopy and proctoscopy. Prolapsed internal hemorrhoids (that come out) are soft, sometimes painful, and can be reinserted into the anus spontaneously or manually.

External hemorrhoids are expansions of the branches that belong to the inferior rectal veins and are covered with anal skin, making them sensitive to touch and painful. Thrombosed external hemorrhoids cause severe pain and have a color that varies from dark red to black. Usually, neither the patient nor the doctor is able to reduce (reposition) this type of hemorrhoids, because they are very painful and do not put the patient in conditions to perform a rectal examination.

Complaints of patients with hemorrhoids may include:

• Bleeding with bright red blood from the rectum, usually not accompanied by pain. The bleeding usually occurs during defecation or it happens that the patient notices blood signs only on the toilet paper. More rarely, the bleeding is noticed spontaneously and regardless of the act of defecation.
• Intermittent rectal bleeding.
• A feeling of prolapse in cases of straining during the act of defecation. The prolapse disappears spontaneously or is alleviated with manual maneuvers.

Symptoms (signs) of external hemorrhoids include:

• A continuous or intermittent feeling of a swollen area around the anus, caused by the presence of:
  • Swollen hemorrhoids that are not thrombosed.
  • Acute hemorrhoidal crisis (thrombosed hemorrhoids).
  • Thrombosed external hemorrhoids that cause severe pain and bleeding with a color that varies from dark red to black.
• Rectal examination is often very painful for the patient, especially when dealing with prolapsed hemorrhoids from the anal canal.
• The spontaneous pain that the patient feels, is often accompanied by prolapsed and thrombosed hemorrhoids.
• Anal itching (pruritus) and a feeling of burning and irritation.
• Rectal secretions and consequently prolapse occur, making the anal area moist, on the other hand, this area becomes sensitive and presents with fine fissures.
• For patients, it becomes impossible to keep the anal area dry.
• Patients may also complain of small involuntary fecal leakages, which can worsen the condition of anal itching.

Even when patients feel they have lost a large amount of blood, hemorrhoid-related hemorrhages are usually mild and rarely lead to anemia. If the patient is suspected of being anemic, a complete blood analysis or sometimes the patient needs to be sent for a gastrointestinal endoscopic examination to confirm or exclude a tumoral pathology. Through a rectal examination, it is possible to discover a rectal carcinoma merely by touch. If the doctor has not been able to completely exclude a rectal or colon carcinoma through a simple anorectal examination, then it will be necessary to perform instrumental endoscopic examinations.

Fig. 3 : Schematic representation of a rectal carcinoma located in a position that can be diagnosed by digital rectal examination.

How should a patient suffering from hemorrhoids be treated:

Before determining a therapy for hemorrhoids, it is necessary to exclude possible more serious pathologies such as colorectal cancer. Patients affected by this serious disease, present more or less the same clinical signs:

• Blood loss from the rectum
• Signs of blood in feces
• Tenemus (straining)
• Abdominal pain
• Disorder of the "intestinal habitus" (disorder of the bowel evacuation habit)
• Weight loss.