The patient’s presentation is most consistent with internal hemorrhoids. Internal hemorrhoids most commonly present as painless rectal bleeding with varying degrees of prolapse.
Hemorrhoids can be divided based on their location relative to the dentate/pectinate line: internal hemorrhoids are above, while external are below. Because of the difference in innervation, external hemorrhoids tend to be painful but not bleed, while internal hemorrhoids tend to be painless but bleed. Risk factors for hemorrhoids include age, pregnancy, pelvic tumors, prolonged sitting, straining, and chronic constipation. Common symptoms include bleeding, pain, pruritus, and prolapse. Treatment depends on severity of disease, and ranges from conservative management with dietary modification, office-based procedures, and surgical hemorrhoidectomy. Painful thrombosed external hemorrhoids may benefit from analgesics, stool softeners, or sitz baths.
Mounsey et al. discuss the approach to hemorrhoids. They suggest that physical exam should include abdominal examination, inspection of the perineum, digital rectal examination, and anoscopy, which is required for diagnosis of internal hemorrhoids. Surgical treatment options for internal hemorrhoids are also discussed, and include rubber band ligation, infrared coagulation, excisional hemorrhoidectomy, and stapled hemorrhoidopexy. Choice of treatment depends on the patient’s symptoms and extent of disease, and on the experience of the surgeon.
Shanmugam et al. performed a review of randomized controlled trials comparing rubber band ligation with excisional hemorrhoidectomy. They found that, for grade III hemorrhoids (prolapse out of the anal canal requiring the patient to reduce them to normal position), excisional hemorrhoidectomy has greater long term efficacy. However, the patient is subject to greater pain and more time off from work, and has a higher risk of complications.
Illustration A depicts the anatomy and location of the different types of hemorrhoids.
Illustration B depicts a prolapsed internal hemorrhoid on anal exam.
Illustration C depicts a thrombosed external hemorrhoid on anal exam.
Answer 1: Ulcerative colitis is unlikely as there is no abdominal discomfort, no mucus in the stool, and no diarrhea.
Answer 2: External hemorrhoids would likely be painful.
Answer 3: Colorectal cancer in a 25 year old is less likely, especially without family history or history of ulcerative colitis.
Answer 5: Anal fissures are common in patients with chronic constipation, but are typically painful.
Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician. 2011 Jul 15;84(2):204-10.
PMID:21766771 (Link to Abstract)
Shanmugam V, Thaha MA, Rabindranath KS, Campbell KL, Steele RJ, Loudon MA. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul 20;(3).
PMID:16034963 (Link to Abstract)
USMLE Step 2 CK Qbook 4th ed. Daugherty, Stephen R. New York: Kaplan Publishing, 2008.