Hemorrhoids Differential Diagnosis Table

In this video, I attempted to explain some of the things that truly help with hemorrhoids. Patients with hemorrhoids are often scared, and they experience bleeding, itching, or simply pain and a rectal prolapse. These symptoms are often present in other life-threatening conditions, so it is extremely important to learn about the diagnostic procedures and possible similarly dangerous causes.

Down below, you will find what we refer to in medicine as a “differential diagnosis table”.

Differential diagnosis tables help us learn how to diagnose a disease and how to distinguish it from other similar diseases! In our interactive table below, we attempted to include all the similar diseases and their symptoms so that we don’t skip a single important sign or disease!

Hemorrhoids Differential Diagnosis Table:

Every human being has hemorrhoidal tissue, as a part of human anatomy, that acts as vascular cushions in the anorectal region. In some instances, excessive pressure results in symptomatic enlargement of these vascular tissues resulting in hemorrhoidal disease.
Hemorrhoids, also known as piles, are one of the oldest conditions affecting mankind as the first mention can be traced in the Bible, centuries ago. They are a rare finding among youngsters and are most commonly present in people between 45 and 64 years of age.
Internal hemorrhoids sometimes do not produce any symptoms. When they do, the most common symptoms include bright red color bleeding from the anus (hematochezia), prolapse which usually causes discomfort with the perineum and anal itching, mucous discharge, a sensation of stuck stool, fecal incontinence, and tenesmus.

How To Distinguish Hemorrhoids from Other Diseases

Distinguish Anal Cancer from Hemorrhoids – Diagnosis

Anal cancer refers to the malignant transformation of cells in the anal area. The symptoms which distinguish them from internal hemorrhoids include:

• Internal hemorrhoids usually present with prolapse in advance stage while in anal cancer it’s rare to find such a thing.
• Similarly, fecal incontinence more commonly seen in patients with hemorrhoids is only seen in anal cancer advanced stages.
• Moreover, the common findings typical of malignancies such as unexplained weight loss, nausea, and fatigue are rare findings in hemorrhoids.

“During the history-taking, patients should be asked about their past medical history related to HPV/AIDS. Literature suggests a link between anal cancer and HPV, and it’s not linked to hemorrhoids. Furthermore, during the examination, hemorrhoids are usually softer to palpation, while the anal cancer lump is harder and rough. Biopsy is the diagnostic test to differentiate the two.”

Distinguish External Hemorrhoids from Interanl Hemorrhoids – Diagnosis

External hemorrhoids occur when the inflamed blood vessels in the anorectal region become so enlarged they protrude out of the anus.

• External hemorrhoids usually present with a burning sensation and pain. A less common finding in internal hemorrhoids.
• Alternatively, internal hemorrhoids cause bleeding as they are along the lining of the rectum, which is a fragile structure.
• External hemorrhoids always bulge out of the anus while the internal hemorrhoids prolapse only in advance stages (stage 3 and 4).

“During the physical examination, typically during anoscopy, if the hemorrhoids are above the dentate line, they are considered as internal hemorrhoids and below as external hemorrhoids.”

Distinguish Anal Fissures from Hemorrhoids – Diagnosis

Anal fissures are the superficial lacerations or tears on the anus lining from trauma, hard stools, and infections. The most striking difference between hemorrhoids and anal fissures is the nature of pain.

• Hemorrhoids are not always painful; however, fissures are extremely painful, especially during and after passing stool. Pain usually lasts hours after defecation.
• Hemorrhoids cause constant pain throughout the day, unlike the episodes of pain with fissures.

Distinguish Anal Fistulae from Hemorrhoids – Diagnosis

Anal fistula is an abnormal epithelial connection between the anal canal and the skin around the anus, usually appearing after anorectal abscess.

• Anal fistula usually presents with typical infection symptoms like fever, chills, and pus discharge, while hemorrhoids rarely present with these.
• There is a visible opening present in the perianal area upon visual inspection in the case of a fistula.

Distinguish Perianal Abcess from Hemorrhoids – Diagnosis

Perianal abscess is a red, swollen lump filled with pus in the perianal area. Just like anal fistula, perianal abscesses are usually very painful, tender to touch, can complicate and result in pus discharge, fevers, and chills. Another visible difference is a mass filled with liquid.

Distinguish Pedunculated Polyps from Hemorrhoids – Diagnosis

Pedunculated polyps are tissue growths with a head attached to the mucous membrane of the colon by a stalk.

• Pedunculated polyps are commonly associated with bowel changes like constipation and diarrhea. However, internal hemorrhoids usually do not cause these.
• As both of them are extremely similar in their presentation, colonoscopy is usually done to differentiate the two.

Distinguish Pruritis Ani from Hemorrhoids – Diagnosis

Pruritus ani is the condition in which the perianal skin is irritated in such a way that it causes itching.

• Internal hemorrhoids have a range of symptoms like bright red color bleeding during defecation, mucous discharge, fecal incontinence, and prolapse. Itchy anus is one of the symptoms of internal hemorrhoids and should not be confused with it.

Distinguish Rectal Prolapse from Hemorrhoids – Diagnosis

Rectal prolapse is a condition of muscle deterioration in which the rectum drops from its usual position and comes out through the anus.

• Internal hemorrhoids do not always result in prolapse; this occurs only in stage 3 and 4.

“The difference is usually made through visual examination where internal hemorrhoids show radial folds, while rectal prolapse shows circular folds.”

Distinguish Rectal Varices from Hemorrhoids – Diagnosis

Rectal Varices are a consequence of liver disease that causes dilation of blood vessels in the rectum submucosa.

• Bleeding is a rare manifestation of rectal varices when compared to internal hemorrhoids.
• During imaging, rectal varices show a tubular appearance when compared to the lump-like appearance of hemorrhoids.

Important Red Flags in Hemorrhoids

The diseases mentioned above have symptoms closely resembling each other. So, the diagnosis is tricky and carries a chance of misdiagnosis. Anal fissures are clearly visible as cracks in the anus and usually result in extreme pain during defecation and stay for some time.

The presence of pus with a visible swollen red lump near the anus is a strong indication of an anal abscess. An anal fistula is almost always caused by an anal abscess and can be clearly appreciated in clinical examination. Both of these conditions are considerably painful and can be easily distinguished from others.

It is to be noted that rectal bleeding is a common symptom among internal hemorrhoids, anal cancer, anal fissure, polyps, and rectal prolapse. The presence of a lump with risk factors for cancer must be evaluated with caution to rule out malignancy. The appearance of these conditions can give a slight indication of the nature of the disease.

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