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Indications of doing colonoscopy in a patient with hemorrhoids which is grade 2/1 and bleeds once or twice in 3-4 months ?

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"hemorrhoids"[MeSH Terms] AND "colonoscopy"[MeSH Terms]

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Grade 1/2 hemorrhoids that bleed once or twice every 3-4 months do not by themselves need a colonoscopy. A colonoscopy is indicated when a risk factor or red flag is present, or when the colon has not been screened. Hemorrhoids can be the true cause, but they should not be assumed to be.

Do colonoscopy if any of these apply

  1. Age. Two textbooks give different thresholds:
    • Textbook of Family Medicine says patients older than 40 with hemorrhoidal bleeding may have other colorectal pathology and need further evaluation (Textbook of Family Medicine 9e, Internal Hemorrhoids).
    • Goldman-Cecil lists unscreened individuals over 45 as high risk and says to do a full colonoscopy (Goldman-Cecil Medicine, Ch. 131).
    • If the patient is 45 or older and has never had a screening colonoscopy, this is the clearest indication, even if the bleeding is only occasional.
  2. Family or personal history. This means colorectal cancer, adenomatous polyps, or inflammatory bowel disease in the patient or a first-degree relative.
  3. Bleeding that persists or recurs despite adequate treatment. This means continued bleeding after fiber, stool softeners, or banding (Goldman-Cecil Medicine, Ch. 131).
  4. Bleeding site not clearly identified. If anoscopy does not clearly show the hemorrhoid as the source, a colonoscopy is needed (Textbook of Family Medicine 9e).
  5. Occult or atypical bleeding. Yamada states that "Occult bleeding should never be attributed to hemorrhoids." Also consider colonoscopy if:
    • the blood is mixed with the stool or dark
    • there is iron deficiency anemia
    • the bleeding is not bright red or not at the end of defecation
    • the blood is not separate from the stool (Yamada's Textbook of Gastroenterology, 7e)
  6. Red-flag symptoms. These are:
    • change in bowel habit
    • unexplained weight loss
    • abdominal pain
    • tenesmus
    • mucus in the stool
    • anemia
    • a palpable mass
    • positive fecal occult blood or FIT test

When you can reasonably skip it

Yamada makes an exception for a young patient with a typical hemorrhoidal pattern. That means:
  • bright red blood on the tissue or dripping into the bowl, at the end of defecation and separate from the stool
  • a hemorrhoid seen on anoscopy
  • no risk factors or red flags
In that case, treat the hemorrhoids and follow up. Even then, the textbooks advise at least a limited evaluation, such as anoscopy or flexible sigmoidoscopy. Goldman-Cecil says that "Rectal bleeding should never be attributed to hemorrhoids alone, even if hemorrhoids are visible."
Colon and rectal cancers are becoming more common in people under 45, so unexplained rectal symptoms need a proper evaluation at any age. Mulholland and Greenfield's Surgery also says colonoscopy is still necessary when hemorrhoids are present, to exclude a more serious source of bleeding.

Practical approach for your patient

  1. Take a history for red flags, family history and screening status.
  2. Do a digital rectal exam and anoscopy.
  3. Check hemoglobin and ferritin.
  4. Colonoscopy if: age 45 or older and unscreened, any red flag or family history, anemia, or the bleeding persists after treatment.
  5. Otherwise: manage conservatively with fiber, fluids and stool softeners, and consider banding if symptoms continue. Advise the patient to return if the pattern changes.
A quick PubMed check of recent meta-analyses and systematic reviews found nothing that updates or contradicts these recommendations.
Sources:
  • Textbook of Family Medicine 9e, Internal Hemorrhoids
  • Goldman-Cecil Medicine, Ch. 131 (Table 131-1)
  • Yamada's Textbook of Gastroenterology, 7e, Internal hemorrhoids
  • Mulholland and Greenfield's Surgery, 7e, Internal Hemorrhoids
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