Banding for Internal Hemorrhoids

History

The definitive diagnosis of hemorrhoidal disease can be made almost always if a careful history is taken, paying particular attention to the colour and character of the bleeding, the relation of discomfort to defecation and the unequivocal history of relief from reduction of the prolapse into the anal canal. The importance of detailed assessment by endoscopy in establishing the diagnosis is to exclude the other often more dangerous causes of rectal discharge, prolapse, anal pain and bleeding.

Inspection

Discharge from everted anal canal mucosa in third-degree piles (see below) is readily seen if the patient is examined when comfortable and relaxed in the left lateral position and when he or she can be persuaded to bear down. This maneuvre will also allow differentiation of true full-thickness rectal prolapse from simple internal cushion prolapse. Alternatively, the patient can be examined in the prone position on a special proctologic table, this being the preferred technique in the USA. A good light, careful inspection and palpation may be required to differentiate hemorrhoidal discharge from a chronic fistula-in-ano or from perianal Crohn's disease.

Palpation

After inspection, palpation is the next important method of assessment mainly to help exclude other pathology since hemorrhoids, unless thrombosed, are not usually palpable. It is important to stress the need for gentleness in palpation for painful anal conditions. The examination must be performed slowly with adequate lubrication; local anesthesia may be required. In the absence of an episode of thrombosis, acute anal pain is a rare feature of uncomplicated hemorrhoidal disease. Its presence should make one suspect a fissure-in-ano, which is best diagnosed by inspection; an abscess, which should be detected readily by its localized induration, redness and pain; or anal carcinoma, which can be recognized by palpating its hard edge on digital examination. Solitary rectal ulcer may sometimes be identified by palpation.

Endoscopy