Diagnosis & Examination

Rectal bleeding should not automatically be assumed to come from hemorrhoids. A familiar bleeding pattern still deserves an appropriate assessment, especially when it is new, persistent, changing, unexplained, or accompanied by other bowel or general symptoms.

Assessment combines history, inspection, selective digital rectal examination, and anoscopy. Colon evaluation is added when the history, examination, colorectal cancer risk, or screening status indicates that a more proximal source must be assessed. [1]

History

The clinician asks about blood color and amount, relation to stool, prolapse, pain, itching, mucus, soiling, bowel habit, duration, prior episodes, treatments, medicines that affect bleeding, family history, and colorectal screening. Weight loss, anemia symptoms, abdominal pain, altered bowel habit, or blood mixed through stool may broaden the evaluation.

Inspection and palpation

External inspection can identify thrombosis, skin tags, fissure, prolapse, dermatitis, fistula openings, or swelling. Asking the patient to bear down may reveal prolapse. A digital rectal examination, when appropriate and tolerable, assesses masses, tenderness, sphincter function, and blood, but normal palpation does not exclude internal hemorrhoids.

Anoscopy

Anoscopy allows direct inspection of the anal canal and can show internal hemorrhoidal cushions, bleeding, inflammation, or another local lesion. Findings must match the symptom pattern; seeing hemorrhoids does not prove they are the source of every episode of bleeding. [2]

Selective colon evaluation

Endoscopic evaluation of the rectum or colon is considered when there is no clear anorectal source, concerning associated symptoms, relevant personal or family risk, iron-deficiency anemia, persistent bleeding after treatment, or a need for age- and risk-appropriate colorectal screening. The extent and urgency depend on the clinical context.

Differential diagnosis

Common alternatives include anal fissure, colorectal polyps or cancer, proctitis, inflammatory bowel disease, diverticular bleeding, angiodysplasia, rectal prolapse, abscess, and dermatologic disease. Severe pain is a reason to look beyond uncomplicated internal hemorrhoids.

Reassessment

If treatment does not improve the presumed hemorrhoidal symptom, the diagnosis should be revisited rather than repeatedly escalating treatment without confirmation.