Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. Visual confirmation of internal hemorrhoids requires Anoscopy, a hollow tube device with a light attached at one end. There are two types of hemorrhoids: external and internal. These are differentiated by their position with respect to the dentate line. A rectal exam may be performed to detect possible rectal tumors & polyps.
Internal hemorrhoids are those that originate above the dentate line. They are covered by columnar epithelium which lacks pain receptors, that the reason that they are painless. They were classified into four grades based on the degree of prolapse.
- Grade I: No prolapse. Just prominent blood vessels.
- Grade II: Prolapse upon bearing down but spontaneously reduce.
- Grade III: Prolapse upon bearing down and requires manual reduction.
- Grade IV: Prolapsed and cannot be manually reduced.
External Hemorrhoids - External hemorrhoids are those that occur below the dentate or pectinate line. They are covered proximately by anoderm and distally by a skin, both of which are sensitive to pain and temperature.
The primary concern of patients with rectal bleeding is the possibility of colorectal cancer. Other diagnoses that may need to be excluded include colitis like inflammatory bowel disease, diverticular disease, and angiodysplasia. More extensive endoscopic evaluation with complete colonoscopy or flexible sigmoidoscopy is indicated in following conditions
- Positive fecal occult blood test
- Iron deficiency anemia
- Family history of colorectal cancer or polyp
Medical treatment - Medical treatment includes a diet rich with fibers, intake of oral fluids to maintain hydration and sitz baths.
Office Procedure (Treatment) - A number of office-based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur. Blood tests to measure your blood counts, your risk of bleeding or infection, how well your liver and kidneys are working and blood grouping, in case you need a blood transfusion.
Chest x-ray and ECG (electrocardiogram) to check your lungs and your hearts electrical system.
Rubber band ligation is typically recommended as the first line treatment in those with grade 1 to 3 disease. It is a procedure in which elastic bands are applied on to internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5"7 days, withered hemorrhoid falls off. Cure rate has been found to be about 87% with a complication rate of up to 3%.
Sclerotherapy involves the injection of a sclerosing agent, such as phenol, into hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is ~70% which is higher than that with rubber band ligation.
Cauterization methods: A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually only used when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery or cryosurgery. These methods may be an option for grade 1 or 2 diseases. In those with grade 3 or 4 disease re-occurrence rates are high. Rubber band ligation and Sclerotherapy.