Diagnosis

Abstract

It is frequently taken for granted that the diagnosis of haemorrhoids is easy. Two assumptions underlie this view — one, that a patient complaining of bleeding on defaecation, especially one below thirty years of age, is virtually certain to be suffering from haemorrhoids, and two, that the diagnosis does not need to be confirmed by a meticulous process of examination that is designed to exclude other (and often much more serious) conditions; both are wrong. The clinician must always keep the possibility of alternative causes of the bleeding in his mind, and only reach the diagnosis of haemorrhoids when all other causes have been excluded. This may require not only a trained specialist in coloproctological disorders, but backup with endoscopic, radiologic and haematological investigations. Most medical students at some stage are taught the well-known aphorism “if you do not put your finger in it [anus], you may put your foot in it”. While this nostrum highlights the absolute requirement of a digital examination in any case presenting with bleeding per rectum, it also carries the unfortunate and misleading message that this is all that is required. As will be seen from later discussions, this is very far from the truth, regardless of the age of the patient. Not only does the diagnosis of haemorrhoids require examinations additional to the insertion of the index finger, it disregards the vital importance of a detailed history for making the diagnosis; medical students should be taught a second aphorism, viz., “that if you do not obtain a proper history, you will form part of medico-legal history”.