Examination of Haemorrhoids

Background

Grading (Degrees) of Internal Haemorrhoids

Clinical Symptoms

• Bleeding - the earliest symptom; bright red, painless, separate from the stool; seen on toilet paper or as a fresh "splash in the pan"
• Prolapse - lump appearing at the anal orifice (2nd-4th degree)
• Pruritus - from mucous discharge
• Mucous discharge - common with prolapsed haemorrhoids
• Pain - NOT typical of uncomplicated haemorrhoids; pain should alert to another diagnosis such as anal fissure or thrombosis
• Anaemia - with chronic significant bleeding (3rd-4th degree)

Examination Setup

• A relaxed, informed patient
• A private environment with a chaperone
• Good light
• Personal protective equipment

Positions for Examination

Step 1: General Examination

• Constipation
• Pregnancy (venous compression + excess progesterone relaxing vessel walls)
• Urethral stricture, enlarged prostate, pelvic tumours (pressing on superior rectal veins)
• Evidence of anaemia (with prolonged bleeding)

Step 2: Local Inspection

Step 3: Digital Rectal Examination (DRE)

Important point: Uncomplicated internal haemorrhoids cannot be felt on DRE because they are soft and compressible. Digital examination is NOT diagnostic for haemorrhoids unless they are thrombosed or fibrosed.

• Soft tissue induration and tenderness around the anus
• Perianal subcutaneous lesions
• Intrarectal or intra-anal mass
• Sphincter length, resting tone, and voluntary squeeze
• In males: posterior surface of the prostate (anterior wall)
• In females: uterine cervix (anterior wall)
• Puborectalis sling felt posteriorly at the apex of the canal
• Stool colour, blood, mucus, or pus on the withdrawing finger

Step 4: Proctoscopy - The Key Investigation

1. Fully introduce the proctoscope with the obturator in place
2. Remove the obturator under good light
3. Slowly withdraw the proctoscope
4. The red-brown mucosa with the haemorrhoids will bulge into the proctoscope as it is withdrawn
5. The three primary piles are visible at 3, 7, and 11 o'clock (lithotomy position)
6. Ask the patient to bear down on slow withdrawal - may reveal a descending intussusception

Step 5: Sigmoidoscopy

• Rectal pathology is frequently associated with anal lesions
• It is mandatory to exclude serious proximal pathology - particularly carcinoma of the rectum
• Any doubt about the origin of rectal bleeding warrants further investigation (colonoscopy or barium enema)

If there is any doubt about the diagnosis of haemorrhoids, examination under anaesthesia and/or endoscopic visualisation are necessary.

Summary of Examination Steps

1. General examination - identify predisposing causes (constipation, pregnancy, prostate, pelvic mass)
2. Position the patient - left lateral (Sims) position most commonly
3. Inspection - buttocks parted; look for prolapse, skin tags, skin lesions, fistulae, sentinel pile
4. Digital rectal examination - assess tone, masses, tenderness; note that uncomplicated piles are impalpable
5. Proctoscopy - definitive diagnosis; haemorrhoids bulge into scope on withdrawal at 3, 7, 11 o'clock
6. Sigmoidoscopy - mandatory to exclude rectal carcinoma and other proximal pathology

Key Clinical Reminders

• "If you don't put your finger in, you might put your foot in it" - DRE is essential for any patient with anorectal/bowel symptoms (Bailey & Love)
• Bright-red painless bleeding is characteristic; pain should always raise suspicion of a concurrent diagnosis (fissure, thrombosis, carcinoma)
• Symptomless haemorrhoids should not be treated
• Symptoms spontaneously come and go; reassure the patient after full examination and address constipation
• Always exclude colorectal malignancy before attributing bleeding to haemorrhoids

Examination of Liposarcoma

What is Liposarcoma?

Subtypes at a Glance

Clinical Presentation

• Asymptomatic mass - the most common presentation; often noticed incidentally or after minor trauma draws attention to a pre-existing lesion
• Size: tumours in distal extremities tend to be smaller at presentation; proximal extremity and retroperitoneal tumours can grow very large before becoming apparent
• Retroperitoneal liposarcoma: typically presents as a mass >10 cm; symptoms arise late when the tumour compresses surrounding structures - pain, early satiety, obstructive GI symptoms, or neurological symptoms from lumbar/pelvic nerve compression
• Pain: occurs with impingement on bone or neurovascular bundles; more typical of high-grade or large tumours
• Tumour growth: centrifugal - compresses but initially does not invade surrounding normal structures
• Lower extremity DVT may occasionally be the presenting feature (tumour compressing venous outflow)

History Taking

Physical Examination

General Examination

• Overall appearance: look for signs of anaemia (chronic bleeding retroperitoneally), weight loss, cachexia
• Lymph nodes: a complete nodal examination of all nodal basins is mandatory - though lymph node metastasis is rare in liposarcoma (<5% of soft tissue sarcomas overall), it must be excluded
• Testicular examination in men: retroperitoneal mass differential includes testicular primaries (germ cell tumours) - elevated AFP/beta-HCG should be checked

Local Examination of the Mass

"Enlarging masses and masses larger than 5 cm or deep to the fascia should be evaluated with a history, imaging, and biopsy." - Schwartz's Principles of Surgery, 11th Ed.

Distinguishing Features from Lipoma (Differential)

• Deep location (beneath investing fascia)
• Size >5-10 cm
• Firmness or heterogeneity on palpation
• Fixed or non-mobile
• Rapid growth
• Pain (lipomas are typically painless)
• Age >50 years with retroperitoneal location

Investigations

Imaging

• Shows fat signal in well-differentiated subtypes
• Features favouring malignancy over a benign lipoma:
  • Size >10 cm
  • Thick, nodular septa
  • Globular or nodular non-adipose areas
  • Fat content <75%
  • Septal enhancement on contrast
  • Incomplete fat suppression

• High-grade tumours >5 cm
• Myxoid liposarcoma (also CT abdomen/pelvis - metastasises to soft tissues)

Well-differentiated liposarcoma can be diagnosed by CT imaging alone - negative biopsy should not delay operative intervention if CT is diagnostic.

Histopathology

• Immunohistochemistry (MDM2, CDK4 for WDL/dedifferentiated)
• Conventional cytogenetics
• FISH for MDM2 amplification (12q13-q15)
• PCR for t(12;16) in myxoid liposarcoma

Biopsy

• Core needle biopsy - preferred for extremity and truncal lesions; performed by the operating surgeon at a sarcoma centre; incision oriented longitudinally along the extremity
• Incisional biopsy - for lesions where core needle is inadequate
• Excisional biopsy - only for superficial lesions <3 cm
• FNA - generally inadequate; only at institutions with specialist cytopathology expertise
• Important: diagnostic imaging should be performed before biopsy to avoid swelling/haemorrhage artefact

Pathological Staging (AJCC)

• Histologic grade (most important prognostic factor)
• Tumour size (≤5 cm vs. >5 cm; retroperitoneal: most are >10 cm at diagnosis)
• Depth (superficial vs. deep)
• Nodal/distant metastasis

Complications of Liposarcoma

Summary: Examination Checklist

1. History - duration, growth rate, pain, systemic symptoms, family/cancer history
2. General - anaemia, weight loss, lymphadenopathy, testicular exam (in men with retroperitoneal mass)
3. Local mass - site, size, depth, consistency, mobility, skin involvement, neurovascular status
4. Imaging before biopsy - MRI for extremity; CT for retroperitoneal
5. Core needle biopsy at a sarcoma centre, longitudinal incision
6. Chest CT for staging (high-grade or >5 cm)
7. Staging workup - CT chest/abdomen/pelvis for myxoid liposarcoma specifically
8. Multidisciplinary team - radiologist, pathologist, surgical oncologist, medical and radiation oncologist

Examination of the Abdomen

Setup and Patient Position

• Lie flat on the back, hips and knees extended (or slightly flexed to relax abdominal muscles during palpation)
• Expose the abdomen from the nipples above to the saphenous openings below (including inguinal and femoral rings)
• Examine in good light (preferably daylight)
• Warm hands before examining; gain the patient's confidence

General Examination (Before Local Exam)

Regions of the Abdomen

1. INSPECTION

A. Hernial Orifices

• Inspect first - inguinal, femoral, umbilical, and incisional hernia sites
• Ask the patient to cough to detect an impulse (positive = hernia)
• "If this examination be left for the last it may be missed and actual cause of acute abdomen may thus remain in the dark" - S. Das

B. Contour of the Abdomen

C. Respiratory Movement

• Normal: abdomen rises and falls freely with respiration
• Absent or sluggish: widespread peritoneal irritation - diffuse peritonitis (peptic perforation, haemorrhage from ruptured ectopic gestation)
• Localised limitation: localized peritonitis (acute cholecystitis, appendicitis)

D. Visible Peristalsis

• Watch patiently for a few moments
• "Ladder pattern" - small bowel obstruction
• Left-to-right wave from left hypochondrium - pyloric obstruction / gastric carcinoma
• Right-to-left wave - transverse colon carcinoma

E. Pulsating Swelling

• Visible pulsation in epigastrium - abdominal aortic aneurysm (leaking or intact)

F. Skin

G. Scars

• Previous surgical scars indicate prior operations; their size and location suggest the nature of previous surgery
• Striae (stretch marks) - pregnancy, obesity, Cushing's syndrome

H. Dilated Veins

• Caput medusae (periumbilical radiating veins) - portal hypertension with recanalization of umbilical vein
• Flow direction: in portal hypertension, flow is away from umbilicus; in IVC obstruction, flow is upward above umbilicus and downward below
• Scrotum inspection - always inspect; testicular malignancy metastasizes to para-aortic nodes (swelling here may be the first presentation)

2. PALPATION

Technique

• Use the volar surfaces (flexor surfaces) of the fingers - never poke with fingertips held vertical
• Forearm kept horizontal at the level of the abdomen
• Hand movement at metacarpophalangeal joints only; not at interphalangeal joints
• Begin superficial palpation, then deep palpation (if tenderness allows)
• Start furthest from the site of pain and work towards it
• Watch the patient's face throughout for signs of discomfort
• For palpation: hips and knees flexed to relax abdominal muscles
• Ask patient to breathe through the mouth slowly to reduce voluntary guarding

A. Tenderness

• Note: site, severity, and radiation of tenderness
• McBurney's point (1/3 of the way from ASIS to umbilicus) - appendicitis
• Murphy's sign: palpate under the right costal margin during deep inspiration; the patient catches their breath or winces due to the inflamed gallbladder descending onto the examining fingers - indicates acute cholecystitis
• Rovsing's sign: pressure on the left iliac fossa produces pain in the right iliac fossa - acute appendicitis (coils of ileum shift slightly to the right, pressing on the inflamed appendix)
• Cope's Psoas test: a retrocaecal appendix lies on psoas major; passive extension of the hip (with patient in left lateral position) stretches psoas and causes pain - retrocaecal appendicitis
• Obturator test: internal rotation of a flexed hip causes pain in RIF - pelvic appendicitis

B. Guarding and Rigidity

Voluntary guarding - patient tenses muscles consciously to avoid pain; disappears during expiration; present throughout the abdomen

Involuntary guarding (muscle guard) - reflex spasm of overlying abdominal wall when inflamed viscus touches parietal peritoneum; remains during expiration; localized to the area of pathology

C. Rebound Tenderness (Blumberg's/Release sign)

• Press gradually with each expiration → then suddenly and completely withdraw the hand
• Patient cries out or winces - sign of parietal peritoneal inflammation (peritonitis)
• A gentler method: percussion tenderness (patient winces when the abdomen is percussed) - equally sensitive, less painful for the patient
• Pain on coughing also indicates rebound tenderness
• In acute intestinal obstruction, the presence of rebound tenderness suggests strangulation

D. Examining an Abdominal Mass

E. Liver Palpation

• Start in the right lower quadrant and move upward toward the rib cage, so the liver edge is felt on the way up
• Patient takes deep breath - normal liver edge may be felt up to 2 cm below the right costal margin
• Normal edge: smooth, slightly tender on deep inspiration in thin subjects
• Hard, irregular: cirrhosis
• Tender, enlarged, smooth: acute hepatitis (viral, alcoholic), hepatic congestion (right heart failure)
• Scratch test: bell of stethoscope over right upper quadrant; scratch from mid-abdomen upward - sound is amplified over the liver; useful when liver edge is unclear

F. Spleen Palpation

• Healthy spleen is NOT normally palpable
• Enlarged spleen descends downwards, forwards and medially
• Start in right lower abdomen with fingertips pointing upward; move gradually toward the left hypochondrium with each breath
• If not palpable supine, repeat in right lateral position
• Characteristic notch on the medial border distinguishes it from other masses
• Percussion: dullness between 9th and 11th ribs in the left midaxillary line = splenomegaly

G. Kidneys

• Bimanual palpation (ballottement): one hand behind the loin, one hand on anterior abdomen
• Enlarged kidney is ballotable - can be bounced between the two hands
• Moves very little with respiration (unlike spleen/liver)
• Renal angle tenderness: tap over the costovertebral angle (renal angle) - tenderness indicates pyelonephritis or renal pathology

3. PERCUSSION

• Moves from resonant to dull areas
• Liver span: normally 6-12 cm in the midclavicular line; diminished in cirrhosis; increased in hepatomegaly (right heart failure, NAFLD, cholestatic cirrhosis)
• Liver: dull to percussion
• Gas under diaphragm: loss of liver dullness / hyperresonance in right hypochondrium = pneumoperitoneum (perforated viscus)
• Splenomegaly: dullness between 9th-11th ribs in left midaxillary line
• Tympany: normal bowel/gaseous distension
• Dullness in flanks → Shifting dullness → confirmed by patient rolling to one side; dullness shifts = ascites
• Fluid thrill: tap one flank, feel vibrations transmitted to the other flank (hand of assistant placed on midline to prevent abdominal wall transmission) - large-volume ascites
• Percussion rebound: patient winces when abdomen is gently percussed = underlying peritonitis (more humane than the classical release sign)

4. AUSCULTATION

A "silent abdomen" is the pathognomonic feature of diffuse peritonitis. A "noisy abdomen" (metallic tinkles) is a feature of mechanical intestinal obstruction.

5. COMPLETION OF ABDOMINAL EXAMINATION

1. All hernial orifices examined (inguinal, femoral, umbilical, incisional) - with cough impulse
2. Digital Rectal Examination (DRE) - mandatory in all acute abdominal cases
   • Tenderness in the right wall of rectum = pelvic appendicitis
   • Tenderness in rectovesical pouch = perforated peptic ulcer
   • Bulging anterior wall of rectum = pelvic abscess
   • "Red currant jelly" on gloved finger (blood + mucus, no faecal odour) = intussusception
3. Vaginal examination in females (if indicated)
   • Tenderness in both fornices + purulent discharge = acute salpingitis
   • Soft cervix + cervical excitation pain = ruptured ectopic gestation
4. Renal angles - tap for tenderness
5. External genitalia - inspect the scrotum routinely (testicular malignancy → para-aortic lymphadenopathy)
6. Thoracic and lumbar spine examination
7. Vital signs and measurement - note abdominal girth in obstruction/ascites for serial comparison

Key Clinical Reminders