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 is the gold standard for diagnosing hemorrhoids in an outpatient setting.
• It allows for direct visual inspection of the anal canal, where internal hemorrhoids originate.
• This visualization is necessary to confirm the diagnosis, assess the severity (grade) of the hemorrhoids, and rule out other local pathologies like fissures or polyps.
• The procedure is quick, minimally invasive, and can be performed easily in a clinical setting without sedation.

Why Other Options Were Wrong

• Option A: An abdominal ultrasound (USG) visualizes solid and hollow organs within the abdominal cavity. It cannot penetrate to or visualize the structures of the anal canal.
• Option B: Sigmoidoscopy examines the rectum and the sigmoid colon, which are located proximal to (higher than) the anal canal. While it can detect other sources of bleeding, it is not the primary tool for visualizing hemorrhoids.
• Option D: A digital rectal examination (DRE) is a crucial part of the initial physical assessment. However, uncomplicated internal hemorrhoids are soft and vascular, making them non-palpable. DRE can only detect them if they are large and thrombosed.

Related Visual

Clinical Relevance

• Nursing practice connection: Use the key finding related to Diagnosis of hemorrhoids to guide bedside assessment, documentation, and the next nursing action.
• Accurate diagnosis of hemorrhoids is crucial because rectal bleeding is also a primary symptom of more serious conditions, including colorectal cancer. Visual confirmation ensures correct treatment and rules out malignancy.
• Nurses play a key role in preparing the patient for a proctoscopy, explaining the procedure to alleviate anxiety, and providing post-procedure care instructions, such as monitoring for increased pain or bleeding.
• What if the patient was 50 years old instead of 30? In that case, even with visible hemorrhoids, a full colonoscopy would be strongly recommended to screen for colorectal cancer, as the risk increases significantly with age.

How to Approach the Question

• First, analyze the patient's presenting symptoms: pain, swelling, and bleeding around the anus are classic signs of hemorrhoids.
• Next, focus on the core question: which test is 'confirmatory' in an 'OPD' (outpatient) setting?
• Evaluate each option's purpose. A 'confirmatory' test must provide a definitive diagnosis, which for hemorrhoids means direct visualization.
• Eliminate USG abdomen as it's the wrong modality for the anatomical area.
• Differentiate between the remaining options. DRE is a manual examination and often misses soft hemorrhoids. Sigmoidoscopy looks too high up in the colon.
• Conclude that Proctoscopy is the only option that directly and specifically visualizes the anal canal, making it the correct confirmatory test in this context.

Concept Tested & Keywords

• Concept Tested: Diagnosis of hemorrhoids
• Stem keywords: haemorrhoids, pain, swelling, bleeding per rectum, confirmatory test, OPD
• Lead-in keywords: What will be
• Clinical cues: Symptoms suggestive of hemorrhoids in a young adult patient.

Question ID

Qxu45BRTSgifpNrSlu-Bbb

Copy ID

Reference Book

E6 Medicine Macleod Clinical Examination 15e p. 134-136

E6 Medicine Harrison 22e Part 2 p. 488-490