What is the approach to history taking and physical exam for a patient presenting with hemorrhoids?

History Taking and Physical Examination for Hemorrhoids

Begin with vital signs assessment, followed by focused history on bleeding characteristics and pain patterns, then perform visual perianal inspection, digital rectal examination, and anoscopy when tolerated. 1

Initial Assessment: Vital Signs and Risk Stratification

• Check vital signs immediately to assess hemodynamic stability, particularly in patients presenting with bleeding 1
• Vital signs including blood pressure, heart rate, and orthostatic changes help stratify bleeding severity and guide urgency of intervention 1
• Document temperature to exclude infectious complications such as perianal abscess or Fournier's gangrene 1

Focused History Components

Bleeding Characteristics

• Ask specifically about timing of bleeding relative to defecation (during, after, or unrelated to bowel movements) 1, 2
• Determine blood color (bright red suggests hemorrhoidal source, dark or maroon suggests proximal bleeding) 1, 2
• Quantify amount: blood on toilet paper only, coating stool, dripping into toilet bowl, or mixed throughout stool 1, 2
• Blood mixed throughout stool warrants colonoscopy as hemorrhoids do not cause this pattern 2, 3

Pain Assessment

• Acute severe anal pain suggests thrombosed external hemorrhoid or strangulated internal hemorrhoid, while painless bleeding is typical of uncomplicated internal hemorrhoids 1, 2
• Pain timing: sudden onset (thrombosis) versus gradual (prolapse, inflammation) 1, 2
• Pain with defecation alone suggests anal fissure rather than hemorrhoids 3, 4

Bowel Habits and Risk Factors

• Document constipation, straining, hard stools, and prolonged time on toilet 1, 2
• Pregnancy status (hemorrhoids occur in 80% of pregnant women, especially third trimester) 5, 3
• Use of anticoagulant or antiplatelet medications increases bleeding risk 1

Red Flag Symptoms Requiring Further Investigation

• Personal or family history of colorectal cancer or inflammatory bowel disease mandates colonoscopy 1, 2
• Unintentional weight loss, change in bowel habits, or abdominal pain suggests alternative diagnosis 1, 2
• Anemia symptoms (fatigue, dyspnea, dizziness) indicate significant chronic blood loss 3

Physical Examination Technique

Visual Perianal Inspection

• Examine perianal area with patient in left lateral decubitus or prone jackknife position for external hemorrhoids, skin tags, thrombosed hemorrhoids, or prolapsed internal hemorrhoids 1, 2
• Look for purple-blue thrombosed external hemorrhoid (acute thrombosis) versus skin-colored prolapsed internal hemorrhoid 1, 2
• Assess for perianal erythema, fluctuance, or purulent drainage suggesting abscess 1
• Note any fissures, fistulas, condylomas, or masses that may mimic hemorrhoids 1

Digital Rectal Examination

• Perform digital rectal examination to assess sphincter tone, palpate for masses, and detect blood 1, 2
• Internal hemorrhoids are typically not palpable unless thrombosed or prolapsed 6, 7
• Assess for tenderness suggesting abscess, fissure, or inflammatory process 1
• Presence of palpable mass requires differentiation between hemorrhoid, polyp, abscess, or malignancy 1

Anoscopy

• Anoscopy should be performed as part of physical examination whenever feasible and well tolerated to directly visualize internal hemorrhoids 1, 2
• Anoscopy allows grading of internal hemorrhoids: Grade I (bleeding without prolapse), Grade II (prolapse with spontaneous reduction), Grade III (prolapse requiring manual reduction), Grade IV (irreducible prolapse) 6, 7
• Anoscopy may be impossible in patients with acute thrombosed hemorrhoids due to severe pain and may require sedation 3
• Visualize bleeding source, degree of prolapse, and presence of ulceration or necrosis 2

Laboratory Investigations

For Bleeding Hemorrhoids

• Obtain complete blood count (CBC) including hemoglobin and hematocrit to assess severity of bleeding 1
• Check serum electrolytes, blood urea nitrogen (BUN), and creatinine for risk stratification 1
• Assess coagulation parameters (PT/INR, aPTT) especially in patients on anticoagulation 1
• Blood type and cross-match should be ordered for patients with signs of severe bleeding 1
• Pregnancy test in women of childbearing age if any possibility of pregnancy 1

For Hemorrhoidal Crisis (Acute Pain)

• No specific laboratory tests are indicated for uncomplicated thrombosed hemorrhoids 1
• Laboratory tests should be performed to exclude other causes of acute anal pain such as abscess or Fournier's gangrene 1

Common Pitfalls to Avoid

• Never blindly attribute rectal bleeding to hemorrhoids without adequate examination, as colorectal cancer, inflammatory bowel disease, and other serious conditions present similarly 2, 3
• Hemorrhoids alone do not cause positive fecal occult blood tests—positive guaiac mandates colonoscopy 2, 3
• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests anal fissure (occurs in 20% of hemorrhoid patients), abscess, or other pathology 3
• Anemia from hemorrhoidal bleeding is rare (0.5 per 100,000 population) and should prompt evaluation for other sources 3
• Do not overlook concomitant anorectal pathology such as abscesses, fissures, inflammatory bowel disease (3.3-20.7% of IBD patients have symptomatic hemorrhoids), or malignancy 1

When Additional Imaging or Endoscopy Is Indicated

Imaging Studies

• Imaging (CT, MRI, or endoanal ultrasound) should be performed only if suspicion exists for concomitant anorectal disease such as abscess, inflammatory bowel disease, or neoplasm 1
• Imaging is not routinely indicated for uncomplicated hemorrhoids 1

Colonoscopy Indications

• Proceed with colonoscopy when concern exists for inflammatory bowel disease or cancer based on patient personal/family history or physical examination findings 1, 2
• Age 50 or above warrants one-time colonoscopy; younger patients may undergo flexible sigmoidoscopy 4
• Colonoscopy is mandatory for blood mixed throughout stool, positive fecal occult blood test, or anemia 2, 3