How Piles Are Diagnosed?

The present time is the era of changing food habits, sedentary lifestyle & mental stress that aids up in disturbing the digestive system resulting in many lifestyle-related diseases. Haemorrhoids is one such common anorectal condition characterized by the dilatation of the venous network & connecting tissue due to altered venous drainage of the anus and sliding down of the anal canal lining creating an outgrowth of anal mucosa from the rectal wall associated with symptoms like anal itching, soiling, rectal bleeding & discomfort.

The inference in contributory factors of piles includes hereditary, excessive straining and obstruction of the blood flow in the rectal veins due to an increase in intra-abdominal pressure. The proper comprehensive history of the patient with the clinical aspects of physical examination is required for proper prognosis and tailor-made management protocol as many people often pin up any anorectal symptom to piles when there may be another reason too.

The common symptoms of hemorrhoids like rectal bleeding, pain, pruritus, or prolapse are extremely comprehensive & are seen in various anorectal conditions. For the best treatment protocol, proper diagnosis with a thorough history & adequate physical examination of the affected part help in precise differential diagnosis to confirm the diagnosis

Diagnosis Of The Piles

In Ayurveda classics, both disorder and patient examination are considered a discrete entities to acknowledge the exact progression of the disease condition in order to get rid of the disease from the root. In this regard, clinical diagnosis is considered as the bench-mark with the art of debriefing the patient to extract the information regarding a present or previous health condition.

What Involves in Diagnosis of Piles:

1. Questioning & cross-examining the patient
2. Physical examination of the patient
3. Observation & analysis of the disease

A: Questioning & Cross-examining Of The Patient

I: Detailed medical history

The foremost requirement for a correct diagnosis is based on listening to the complaints of the patient with extreme patience and cross-questioning accordingly. A carefully detailed history of the present and past medical health condition is a mainstay of clinical diagnosis making.

Assembling & analyzing the important details from the patient’s medical history including details of the eating habits, toilet habits, usage of any laxative medication or enema, suppositories, is required for implied clinical decision making while empathy with patience is apt for patient satisfaction. This basically includes;

1. History & complaints of present illness, past medical history, family history as well as over the counter medication.
2. A proper history of long-standing constipation, cough, and liver disease raises the risk of getting piles.
3. Signs observed by the patient like anal discomfort, soiling of clothes, bleeding type if present, pain & tenderness.
4. Dietary habits, bowel movements, amount of physical activity done, any type of addiction like smoking & alcohol use, or any recent loss of weight marks important in history-taking.
5. Overweight, obese, pregnant and those with a history of anal infections or ascitis are at a greater risk of piles.

II: Eight-fold examination of the patient as per Ayurveda (Ashtavidha Rogi Pareeksha)

The eight-fold examination protocol or ashtavidha rogi pareeksha is practised basically by the Ayurveda physician, aimed at spotting the vitiated dosha that causes the disease. This includes eight features, viz;

1. Pulse Examination: The ayurvedic technique of diagnosis through the pulse is based on the assessment of both physical & mental entities by examining its rate, volume, tension and type of pulsation. 
2. Urine Examination: Urine is the by-product of the metabolism process of the kidney, and is used to detect the blood pressure anomaly, fluid balance, nutrient absorption, and the state of health w.r.t. its frequency during the day & night hours, appearance, clarity, volume, colour, etc.
3. Stool Examination: Stools are metabolic end-products possessing the mirror image of digestion. The proper assessment of the bowel movement frequency, time passed while in toilet straining, any feeling of incomplete bowel evacuation, consistency of the fecal matter, colour, quantity, odour, bleeding or mucus in stools, itching while defaecation, any burning sensation or pain around the anal area, all these give information about the status of the digestive system.
4. Tongue Examination: Tongue is examined w.r.t. the notion of taste, colour, roughness, papillae condition and softness of the tongue surface gives an idea about the degree of digestion and disease condition.
5. Voice Examination: Auscultation by stethoscope for heart rate is examined w.r.t. it’s quality and nature in accordance with the constitution or Prakriti of the individual.
6. Skin Examination: Palpation with palms to assess tenderness on touch, temperature changes, changes in the texture & contour of the skin around the anal area can help to assess the severity of the hygienic condition maintained by the patient.
7. Eye Examination: The changes in the colour, expression, etc reveal the intensity of the morbid doshas and are helpful in the analysis of prognosis.
8. General appearance Examination: The doshic predominance reflects on the face of the patient that might help to evaluate the nature of the disease like neurological problems, nutritional disturbances, disabilities etc.

B. Physical Examination Of The Patient

Physical examination of the patient includes an abdominal examination, visual inspection of the perineum, digital palpation of the rectum, assessment of the neuromuscular functioning of the perineum and proctoscopy if needed. 

I : Inspection & Palpation

The inspection of the abdominal quadrants, anal opening and perianal area is to be performed after the interrogation of the patient signs involved. The inspection & palpation of the perianal and anal area involves below-mentioned findings suggest anorectal conditions like piles;

• Skin changes with dry, lacerated contour with induration & hardness due to itching & soiling.
• Tenderness on touch, redness around the anal area.
• Presence of lump or sprouted swelling
• Leakage of stools with mucus-like discharges over the surrounding area and also on clothes.
• Skin discomfort due to itching & irritation.
• Skin tags may be present 
• The smell of pus, feces and flatus 
• of the perianal and anal region 
• The pile lump coming out of the anus due to prolapse stage
• Pile mass with a blood clot in a vein
• A small tear surrounding the anal opening that may cause itching, pain, or bleeding

II: Digital examination

The patient’s anus and lower part of the rectum are examined in detail to exclude internal hemorrhoids occurrence. This is done after proper counseling and verbal consent of the patient. A sterile gloved finger lubricated with local anesthetic jelly is inserted into the anal canal and after completion the finger is withdrawn.

The digital examination is contraindicated in the following conditions;

1. Without any verbal consent
2. Patient under 16 years of age
3. Without proper counseling & instructions
4. Patient with a history of recent anal/rectal surgery or any trauma in the affected area.
5. Unmarried female (can be performed only with the consent and in the presence of a nurse or female doctor)
6. Non-competent and hesitant patient

Digital rectal examination is mostly done when the following complaints are present;

1. Rectal bleeding (prior to proctoscopy, sigmoidoscopy and colonoscopy).
2. Prolonged constipation history
3. Noticeable changes in bowel habits & frequency.
4. Problems with faecal continence.

A digital rectal examination is helpful in detecting;

1. Anorectal ring thickness
2. The tone of the muscular walls of the anus
3. Any abnormal growth inside the anal canal
4. Tenderness or any bleeding & colour of the blood
5. Anal skin tags, anal lesions
6. Fecal matter
7. Hemorrhoids found with the position, number, grading and prolapse

III: Proctoscopy Examination

The use of a proctoscope i.e. surgical instrument which is inserted into the rectum to check inside of the anal canal, assess the inner walls of the rectum for any abnormality that is not revealed by digital rectal examination. On prcotoscopic examination, the following findings suggest the hemorrhoid type;

• Dilated purplish-blue veins suggest the presence of an internal type of hemorrhoids.
• Dark pink, shining, tender masses at the anal margin marks the 2nd or 3rd grading of prolapsed internal hemorrhoids.
• Less pink, acutely tender with a purplish hue suggests thrombosed external type of hemorrhoids. 

IV: Diagnostic Investigations 

Clinical diagnostic investigations may be required to exclude any serious pathology assessed during the rectal examination and proctoscopic findings.

• A biopsy is done to examine the pathology and rule out other diseases like bowel cancer.
• Complete blood count test to rule out anemia or other bleeding-related ailments.
• Colonoscopy to examine the entire colon with a flexible tube inserted via the rectum.

The diagnosis aspect is done by careful implementation of all of these guidelines to analyze the haemorrhoidal disease severity based upon the observations for deciding treatment modality in terms of diet & lifestyle regime as well as dosha predominance aids in the assessment of the progression of the disease in its early form even before the production of the symptoms. If a  disease is correctly diagnosed,  then treatment is very easy and flawless and, the morbidity and mortality would be minimized.