The diagnosis of hemorrhoidal disease is confirmed through clinical history and physical examination, including a complete proctological examination, which is essential in determining the presence of concomitant conditions [1,2]. It affects approximately 4.4% of the population, with a higher incidence between 45 and 65 years of age, regardless of sex [1]. Adequate anorectal evaluation makes it possible to identify concomitant anal diseases, being crucial for the correct therapeutic planning.

The most common symptoms associated with hemorrhoidal disease are bleeding, pain and prolapse, sometimes confused with the diagnosis of anal fissure, hypertrophied papilla, rectal or anal carcinoma. For its diagnostic differentiation, the use of endoscopic intestinal evaluation is necessary, considered the gold standard for cases of anorectal bleeding, especially in the more advanced age group.

The authors sought to determine the existence of an association between anorectal diseases and bleeding hemorrhoids, using rigid sigmoidoscopy for diagnosis.

So, we ask: Does bleeding hemorrhoidal disease require treatment or investigation?

This is a retrospective study, based on the collection of data obtained from 743 medical records of patients who underwent sigmoidoscopy due to hemorrhoidal disease associated with sporadic hematochezia, at the Coloproctology Outpatient Clinic of the General Surgery Service of the University Hospital of Taubaté-São Paulo, with no distinction of sex, with an approximate distribution of two women for every man, with a higher incidence in the thirtieth and fiftieth age groups. The examination reports were analyzed determining the association of hemorrhoidal disease with perianal fistula, chronic anal fissure, rectal polyp and rectal adenocarcinoma. The percentage of absolute numbers of anorectal diseases associated with hemorrhoidal disease is described.

Patients with a history of malignant neoplasm of the rectum, those submitted to previous radiotherapy, with blood dyscrasia, those without hemorrhoidal disease, those undergoing staging for neoplasm were excluded from the evaluation prostate or uterine cervix and those who had moderate/severe enterorrhagia, as they were directly referred for colonoscopy. All patients underwent bowel preparation at home, starting the day before and ending on the morning of the day of the examination, using fleet enema ® 300 milliliters anally. The patient was encouraged to perform their evacuation at home, before going to the hospital. All patients were informed and agreed to participate in the study, signing the consent form. This work was approved by the Bioethics Committee of the University of Taubaté (protocol CEP/UNITAU 0399/07).

The reports of 743 sigmoidoscopy performed in patients with hemorrhoidal disease concomitantly or not, of those with results of anatomopathological exams, were analyzed and of these 200 (26.9%) had hemorrhoidal disease grade I, 340 (45.8 %) grade II, 147 (19.8%) grade III and 56 (7.5%) grade IV; and in 167 cases (22.5%) we found associated anorectal diseases.

Individuals with hemorrhoidal disease presented concomitance with other anorectal diseases in the following distribution: hemorrhoidal disease grade I, six (3.0%) with perianal fistula and 50 (25.0%) with anal fissure; grade II, 17 (5.0%) with perianal fistula and 22 (6.5%) with anal fissure; grade III, six (4.1%) with perianal fistula and 12 (8.2%) with anal fissure and grade IV, one (1.8%) with perianal fistula, as described in Table 1.

Analyzing the coexistence with polyps, it was observed that of the individuals who had grade I hemorrhoidal disease, one (0.5%) had a tubular adenoma and two (1.0%) had an inflammatory polyp; grade II, three (0.9%) had villous adenoma, two (0.6%) had tubular adenoma and six (1.8%) had inflammatory polyp; grade III, seven (4.8%) had a villous adenoma, none had a tubular adenoma and four (2.7%) had an inflammatory polyp; no coexistence with grade IV hemorrhoidal disease, as described in Table 2.

When correlating the presence of malignant tumors in patients with hemorrhoidal disease, we found: two cases (1.0%) of invasive adenocarcinoma and one case (0.5%) of undifferentiated adenocarcinoma in grade I hemorrhoidal disease; in grade II, eight patients (2.4%) had invasive adenocarcinoma and five (1.5%) had undifferentiated adenocarcinoma; in grade III, ten cases (6.8%) of invasive adenocarcinoma and one (0.7%) of undifferentiated adenocarcinoma were found; in grade IV there was no case of invasive adenocarcinoma and only one patient (1.8%) had undifferentiated adenocarcinoma, as described in Table 3.

Table 1: Association of Anal Fistula and Anal Fissure According to with The Degree of Hemorrhoidal Disease

Table 2: Association of Benign Tumors with the Degree Of The Disease Hemorrhoidal

Table 3: Association of Malignant Tumors with The Degree of Disease Hemorrhoidal

Patients who have hemorrhoidal disease, in its various stages, associated with anal bleeding and who are over 40 years of age should undergo an endoscopic examination (flexible recto sigmoidoscopy and/or colonoscopy) to rule out the possibility of the presence of a benign colorectal tumor or malignant, inflammatory bowel disease and colonic diverticulosis, associations that can be found in up to 9.8% of cases [3]. Bleeding should be considered an alarm symptom for the diagnosis of malignant neoplastic colorectal lesions located in the left hemi-colon, being the same, evaluated through flexible sigmoidoscopy for young and medium risk patients, leaving the option of colonoscopy for over 50 years old [4]. Most patients referred for treatment and evaluation of hemorrhoidal disease are free of any other associated disease, however, in individuals over 40 years of age, the incidence of additional diseases increases significantly and flexible sigmoidoscopy is indicated [5].

Patients with prolapsed hemorrhoids were more likely to have a correct diagnosis, while patients who had pain or itching were more likely to be misdiagnosed [6,7].

In this study, when analyzing the association of the degree of hemorrhoidal disease with concomitant anorectal diseases, we observed a higher prevalence of malignant tumors and polyps in grades II and III and of fistulas and fissures in grades I, II and III.

Studies show that the anorectal diseases most commonly found in association with hemorrhoidal disease are anal fissure, anal papilla hypertrophy, condyloma acuminatum, perianal tumors and anal fistulas [8], however, in our study, we observed exclusively the occurrence of fistulas anal, fissures and malignant tumors and polyps. In a series of 9,289 cases of patients with hemorrhoidal disease, 12.1% were associated with other anorectal diseases, with the majority (5.8%) corresponding to anal fissures [9]. In another study with 2,038 cases of hemorrhoidal disease, 16.9% of anal fissures were found [10]. In our series, the coexistence of other anorectal diseases was evidenced in 27% of the cases, a higher rate than that found in the literature, with 11.3% of the cases being represented by anal fissures.

Hemorrhoidal disease can coexist with malignant and benign lesions in up to 9.8% of cases and be associated with perianal tumors in 0.03% of cases [11]; in our study, in 3.4% cases there was association with benign tumors and in 3.8% with malignant tumors.

Intestinal evaluation performed by endoscopic methods is considered the gold standard investigation for cases related to hematochezia, but other imaging tests may be useful in selected cases. Older patients will need to have a full colon investigation, while younger, low-risk patients may be considered for flexible sigmoidoscopy. The presence or absence of perianal symptoms, associated with weight loss, changes in bowel habits, chronic anemia and a family history of colorectal cancer, are indicative of colonoscopy. Rectal bleeding alone has a positive predictive value for colorectal malignancy of only 8% in patients older than 50 years. Although age is an important factor to guide the differential diagnosis, it is prudent not to imagine that a young person with hematochezia is not caused by a neoplastic disease, as this can lead to tragically late manifestations. Rectal bleeding initially attributed to hemorrhoidal disease represents the most common opportunity to establish a diagnosis of colorectal cancer [7].

In this study, the authors sought to determine the existence of an association between anorectal diseases and bleeding hemorrhoids, using rigid sigmoidoscopy for diagnosis. They conclude that there is a need for an endoscopic investigation in the face of hemorrhoidal disease associated with hematochezia. Emphasizing with this, that the simple clinical finding, confirming the presence of hemorrhoidal disease should not be accepted as its only diagnosis, especially in cases where hematochezia is the main complaint, given the relatively high incidence of diseases with malignant behavior.

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