**5. Diagnosis**

## **5.1 Differential diagnosis**

Because patients often present with fresh bloody stools and lumps in the anus, the following diseases should be considered: Anorectal malignancy (adenocarcinoma, squamous cell carcinoma, and malignant melanoma), rectal prolapse, prolapsed rectal polyp, anal fistula, anal fissure, Crohn's disease, and condyloma acuminata [2]. Each has different signs and symptoms, so recognizing the signs and symptoms of each will lead to a good diagnosis.

## **5.2 Signs and symptoms**

Bleeding in hemorrhoids is often fresh red blood without pain. This is different from an acute anal fissure, which causes fresh bloody stools accompanied by intense pain because there is an injury in the anal canal skin, which is rich in pain receptor nerves (somatic nerves). The color of the blood in hemorrhoidal bleeding is fresh because the source of the blood is the arteriovenous shunt. Rectal bleeding in rectal carcinoma is often reddish, along with the mucus. Left colon carcinoma is often accompanied by small stools with blood on their surface, while bleeding in the right colon carcinoma is often brown in color with diarrhea. A positive occult blood test should be considered more proximal to the source of bleeding, so a colonoscopy is recommended to detect the source of bleeding [1]. The prolapsed mucosa will secrete mucus which can irritate the anal skin, causing itching. In large hemorrhoids, the patient may feel incomplete defecation or feeling of fullness in the rectum. Pain in hemorrhoids only occurs when a thrombus occurs, especially in the blood vessels under the skin or at grade IV, which is constricted by a strong anal sphincter, causing strangulation [3].

## **5.3 Physical examination**

With the patient in the lithotomy or Sim's position, laying on the left side with maximum flexion in the hip and knee joints, inspections are carried out in the perineal and anal areas to detect possible skin tags, external hemorrhoids, skin inflammation due to irritation by mucus and feces, the presence of fissures or anal fistula. (**Figure 3**). When the prolapsed anal cushion is visible, it is necessary to identify the position and number of the main lumps, the presence or absence of the prolapsed anal canal skin, and the presence of thrombus or ulceration [3].

#### **Figure 3.**

*In Sim's position, spreading the anus by the left and right finger and asking the patient to strain, two nodules can be seen at 03.00, and 07.00 o'clock, in this case, anal fissure can also be seen at 06.00 o;clock (black arrow). (Personal collection).*

Keep in mind that, other than hemorrhoids, other prolapses are rectal prolapse and rectal polyps. In a prolapsed rectal polyp, it will appear as a round lump covered with mucosa and have a stalk (**Figure 4a** and **b**). The rectal prolapse is concentric or circular in shape (not lumpy or no radial indentation), not followed by prolapse of the anal skin, and the finger can enter between the prolapse and the anal canal wall [9]. If during the initial examination there is no prolapsed lump, the patient is asked to strain so that prolapse can occur, or more effectively, the patient is asked to squat and be asked to push into the toilet. In addition to the prolapse examination as mentioned above, wait a while to observe the ability of the prolapsing anal cushion to spontaneously disappear, due to self repositioning, or must be pushed with your fingers [8].

Anal melanoma can affect the anal canal and distal rectum, and the majority of tumors are located within 6 cm proximal to the anal verge. There are two types, melanotic, which consists 70% of cases and amelanotic 30%. Amelanotic melanoma is mostly located in the mucosa. Anal melanoma is a rare anal neoplasm. It accounts for approximately 1–4% of anal neoplasms and is female predominant. The signs are an anal lump, pain, and bleeding [10].

Melanotic anal melanoma can be confused with hemorrhoids with thrombosis, as both cause black discoloration. Hemorrhoid thrombus is usually more painful, and the pain will subside after day 3 due to the shrinkage of the lump. This phenomenon is not found in melanotic anal melanoma. The presence of a satellite nodule is also specific to melanoma (**Figure 5a**). The diagnosis is based on the histological picture

#### **Figure 4.**

*a. Prolapse of rectal polyps, b. the polyps stalk can be seen after retracted outside. (Personal collection).*

#### **Figure 5.**

*Anal melanoma, melanotic type. a. with satellite nodule (arrow), b. infiltration to anal sphincter on CT scan (Personal collection).*

of the biopsy specimen. A CT scan is needed to confirm the degree of infiltration, lymph node involvement, and distant metastasis. In **Figure 5b**, the tumor has already infiltrated the anal sphincter. The abdominal perineal ano-recto-sigmoidectomy (Mile's procedure) with permanent sigmoidostomy is the surgery of choice [1, 10].

The patient should also have a digital rectal examination (DRE). Uncomplicated internal hemorrhoids are often vaguely palpable as a soft anorectal mass that is absent in normal people, but when a thrombus or scar tissue has occurred, something harder or a narrowing due to a stricture may be felt. During DRE, anal sphincter tone, prostate enlargement, and the presence of other abnormalities in the rectum, as well as outside the rectum in women, such as the uterus and adnexa, should also be evaluated. To palpate rectal cancer that cannot be reached by fingers, it can be done bimanually (one hand on the lower abdomen and pressing down) or the patient is asked to push (Valsalva test). When there is a rectal tumor in a high position and mobile, it is often palpable with the maximal position of the finger during a digital rectal examination. Patients with complaints of pain in the rectal area have the possibility of fissures, but there is also the possibility of arthritis of the sacro-coccigeal joint. For this reason, during a digital rectal examination, it should not be forgotten to move the coccyx from the sacrum bone. The presence of arthritis will cause pain with movement [1, 3].

## **5.4 Endoscopy**

During anuscopy, the size of the hemorrhoidal nodule, position, level of inflammation, and the possibility of bleeding should be assessed. When a colonoscopy is performed, the retroflexed position of the scope can see hemorrhoids in the rectum. Likewise, a transparent anoscope can clearly see the anal canal and hemorrhoids. Photo documentation can be made during endoscopy [1–3].

As rectal bleeding is the main complaint of internal hemorrhoid, should a routine complete colon examination be done to rule out other causes of bleeding? American Society of Colon and Rectal Surgeons (ASRC) recommends patients with—a) rectal bleeding, b) positive fecal immunochemical testing (FTT), c) positive FTT-fecal DNA test, d) patients with high risk for colorectal malignancy such as d.1) age 50 years or more if no complete examination within 10 years, d.2) age 40 years or more or 10 years younger with history of first degree relative of colorectal cancer or advanced adenoma diagnosed at age less than 60 years, and d.3) age 40 years or more or 10 years younger with history positive for two first degree relatives with advance adenomas or colorectal carcinomas [8].
