PANCE Blueprint GI and Nutrition (8%)

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Internal vs External Hemorrhoids — Quick Compare

🔑 The rule: Above the dentate line bleeds. Below the dentate line hurts. Internal = visceral nerves → painless bright red bleeding. External = somatic nerves → painful lump, especially when thrombosed.

	Internal	External
Location	Above the dentate line	Below the dentate line
Nerves	Visceral → painless	Somatic → painful
Classic finding	Painless bright red blood on the paper or in the bowl; prolapse	Acutely painful, bluish perianal lump (thrombosed); usually no bleeding
Grading	I–IV by prolapse	Not graded
Diagnosis	Anoscopy (can't be felt on DRE)	Inspection at the anal verge
Office treatment	Rubber band ligation (grade I–III)	Excision if thrombosed < 72 hours
First line for both	Fiber + fluids, sitz baths, short-course topical agents

⚠️ Never band an external hemorrhoid: somatic nerves make it severely painful. Rectal bleeding with age ≥ 45, iron-deficiency anemia, weight loss or a change in bowel habits → colonoscopy before blaming hemorrhoids.

Hemorrhoids are normal vascular cushions (blood vessels, smooth muscle, and connective tissue) in the anal canal; hemorrhoidal disease is when they enlarge, slide down, bleed, or clot (they are not simply varicose veins)

• Risk factors: chronic constipation and straining, prolonged sitting on the toilet, pregnancy, chronic diarrhea, older age, and obesity (portal hypertension causes rectal varices, a different problem)
• Discomfort is a common symptom, especially during bowel movements or when sitting. Other symptoms include itching and bleeding

There are three types of hemorrhoids

• External hemorrhoids are distal to the dentate line
• Internal hemorrhoids are proximal to the dentate line
• Mixed hemorrhoids are located both proximal and distal to the dentate line

Internal hemorrhoids (above the dentate line): painless bright red blood per rectum (visceral nerves above the dentate line do not sense pain)

• Internal hemorrhoids typically manifest with bleeding after defecation; blood is noted on toilet tissue and sometimes in the toilet bowl
• Internal hemorrhoids may be uncomfortable but are not as painful as thrombosed external hemorrhoids
• Internal hemorrhoids sometimes cause mucus discharge and a sensation of incomplete evacuation

Grade IV internal Hemorrhoids. Image: Απόστολος Σταματιάδης, CC BY-SA 2.5, via Wikimedia Commons.

External hemorrhoids (below dentate line): painful when thrombosed (somatic nerves), usually no bleeding

• External hemorrhoids may become thrombosed, resulting in painful, purplish swelling
• Rarely they ulcerate and cause minor bleeding. Cleansing the anal region may be difficult

Thrombosed external hemorrhoid. Image: Ole Gebbensleben, York Hilger and Henning Rohde, CC BY 2.0, via Wikimedia Commons.

Strangulated hemorrhoids occur when protrusion and constriction occlude the blood supply. They cause pain that is occasionally followed by necrosis and ulceration.

Physical examination

• Inspection of the anal verge and perianal area for external hemorrhoids, prolapsed internal hemorrhoids, or other possible causes of anal symptoms (e.g., condylomata)
• Digital rectal examination (DRE) for palpation for masses, tenderness, and characterization of anal sphincter tone

Studies

• Anoscopy is the best way to see internal hemorrhoids (they cannot be felt on DRE unless thrombosed)
• Colonoscopy for bleeding at age 40 or older, and at any age with iron deficiency anemia, atypical bleeding, change in bowel habits, family history of colorectal cancer or IBD, or bleeding that persists after treatment; melena or dark blood → look for an upper GI source

Classification of internal hemorrhoids is based on the degree of prolapse

• Grade I: visualized via anoscopy; do not prolapse below the dentate line
• Grade II: prolapse out of the anal canal with defecation or straining but reduce spontaneously
• Grade III: prolapse out of the anal canal with defecation or straining and require manual reduction
• Grade IV: irreducible and may strangulate

location of internal vs. external hemorrhoids. Image: BruceBlaus, CC BY 3.0, via Wikimedia Commons.

All patients: fiber first

• Fiber 20–30 g/day (e.g., psyllium) plus plenty of water; avoid straining and lingering on the toilet; warm sitz baths
• Short course (7 days or less) of topical hydrocortisone or a topical anesthetic (lidocaine) for symptoms; longer steroid use thins the skin

Internal hemorrhoids that fail conservative care (grade I–III)

• Rubber band ligation is the most effective office procedure; the band goes above the dentate line (painless area)
• Avoid banding with anticoagulants or P2Y12 inhibitors (e.g., clopidogrel), portal hypertension, or immunocompromise → sclerotherapy instead
• Pain, fever, and urinary retention after banding → think pelvic sepsis → urgent evaluation
• Surgical hemorrhoidectomy for grade IV, mixed internal and external disease, or failed banding

Thrombosed external hemorrhoid

• Seen within about 72 hours with severe pain → excision under local anesthesia (better than simple incision and clot evacuation, which tends to recur)
• After 72 hours or already improving → conservative care (sitz baths, NSAIDs, soft stools); it resolves over 7–10 days
• Never band external hemorrhoids