A 30 years old male patient comes in the surgical OPD with pain, discomfort and swelling around the anus and bleeding per rectum. History is suggestive haemorrhoids. What will be the confirmatory test in OPD?

1. A

   USG whole abdomen

2. B

   Sigmoidoscopy

3. C

   Proctoscopy

4. D

   Digital rectal examination

Appeared in: NORCET -4 , 2023

Explanation

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• Proctoscopy (or anoscopy) is the standard procedure for the visual examination of the anal canal, which is necessary to confirm a diagnosis of hemorrhoids.
• It allows the clinician to directly see the hemorrhoidal cushions, assess their size, and determine their grade based on the degree of prolapse.
• This direct visualization is crucial for differentiating hemorrhoids from other causes of rectal bleeding or discomfort, such as anal fissures or rectal prolapse.
• The procedure involves inserting a short, rigid tube (a proctoscope) into the anus, providing clear illumination and view of the anal canal.

Why Other Options Were Wrong

• Option A: An ultrasound of the whole abdomen is used to visualize internal organs like the liver, kidneys, and gallbladder. It cannot visualize the structures of the anal canal.
• Option B: Sigmoidoscopy examines the rectum and the sigmoid colon, which are located proximal to (higher up than) the anal canal where hemorrhoids typically form. While it can identify other sources of bleeding, it is not the primary tool for confirming hemorrhoids.
• Option D: A digital rectal examination (DRE) is a fundamental part of the physical exam but is not a confirmatory test. The examiner's finger can assess sphincter tone and feel for hard masses, but soft, uncomplicated internal hemorrhoids are typically not palpable.

Related Visual

• Visual 1: Diagram - Anatomy of the anorectal region, clearly labeling the anal canal, dentate line, and the location of internal and external hemorrhoidal plexuses.
• Visual 2: Chart - The four grades of internal hemorrhoids, with illustrations showing the degree of prolapse for each stage.
• Visual 3: Illustration - A comparison of the scopes used for Proctoscopy, Sigmoidoscopy, and Colonoscopy, showing the relative length and area of the bowel each instrument examines.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Diagnosis of Hemorrhoids to guide bedside assessment, documentation, and the next nursing action.
• A nurse's role during a proctoscopy includes preparing the equipment, positioning the patient (typically in the left lateral or knee-chest position), and providing reassurance to alleviate anxiety.
• Post-procedure, the nurse should instruct the patient to report any excessive bleeding, severe pain, or difficulty urinating, and monitor for signs of a vasovagal reaction (fainting) immediately after the procedure.
• What if? If this patient were 55 years old instead of 30, even with classic hemorrhoid symptoms, a full colonoscopy would likely be recommended over just a proctoscopy to screen for colorectal cancer, which is a more common cause of rectal bleeding in older adults.

How to Approach the Question

• First, identify the core clinical scenario: a young male with classic symptoms of hemorrhoids (pain, swelling, bleeding near the anus).
• Next, understand the specific question: it asks for the confirmatory test, meaning the test that provides a definitive diagnosis.
• Evaluate each option based on the anatomical area it assesses. USG is for the abdomen. Sigmoidoscopy is for the lower colon. DRE is a manual palpation. Proctoscopy is a visual inspection of the anal canal.
• Reason that to confirm a visual problem like swollen veins (hemorrhoids) in the anal canal, a direct visual inspection of that specific area is required.
• Eliminate DRE because it relies on touch and can miss soft tissue. Eliminate USG and Sigmoidoscopy because they examine the wrong anatomical locations for a primary hemorrhoid diagnosis.
• Conclude that Proctoscopy is the most logical and direct method to confirm the diagnosis.

Concept Tested & Keywords

• Concept Tested: Diagnosis of Hemorrhoids
• Stem keywords: hemorrhoids, pain, swelling around anus, bleeding per rectum, confirmatory test
• Lead-in keywords: What will be
• Clinical cues: 30 years old male
• Clinical cues: symptoms of pain, discomfort, swelling, and bleeding per rectum

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