Editing Hemorrhoid (section)

==Diagnosis==
{| class="wikitable" style="float: right; margin-left:15px; text-align:center"
|+ Internal hemorrhoid grades
!Grade !! Diagram !! Picture
|-
|1|| [[File:Piles Grade 1.svg|140px]]||[[File:Haemorrhoiden 1Grad endo 01.jpg|140px|Endoscopic view]]
|-
|2|| [[File:Piles Grade 2.svg|140px]]||[[File:Hemrrhoids 04.jpg|140px]]
|-
|3|| [[File:Piles Grade 3.svg|140px]]||[[File:Hemrrhoids 05.jpg|140px]]
|-
|4|| [[File:Piles Grade 4.svg|140px]]||[[File:Piles 4th deg 01.jpg|140px]]
|}
Hemorrhoids are typically diagnosed by physical examination.<ref name=NG2011 /> A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids.<ref name=World09 /> Visual confirmation of internal hemorrhoids, on the other hand, may require [[anoscopy]], insertion of a hollow tube device with a light attached at one end.<ref name="Kaidar2007" /> A [[digital rectal exam]] (DRE) can also be performed to detect possible rectal [[tumor]]s, [[polyp (medicine)|polyps]], an enlarged [[prostate]], or [[abscess]]es.<ref name=World09 /> This examination may not be possible without appropriate [[sedation]] because of pain, although most internal hemorrhoids are not associated with pain.<ref name=Review09 /> If pain is present, the condition is more likely to be an [[anal fissure]] or external hemorrhoid rather than internal hemorrhoid.<ref name=Kaidar2007 />

===Internal===
Internal hemorrhoids originate above the pectinate line.<ref name=Day2006 /> They are covered by [[columnar epithelium]], which lacks pain [[sensory receptor|receptors]].<ref name=Beck2011 /> They were classified in 1985 into four grades based on the degree of [[prolapse]]:<ref name=Review09 /><ref name=Beck2011 />

* Grade I: No prolapse, just prominent blood vessels<ref name=NG2011 />
* Grade II: Prolapse upon bearing down, but spontaneous reduction
* Grade III: Prolapse upon bearing down requiring manual reduction
* Grade IV: Prolapse with inability to be manually reduced.

===External===
[[File:Perianal thrombosis 01.jpg|thumb|left|A [[thrombosis|thrombosed]] external hemorrhoid]]

[[Perianal hematoma|External hemorrhoids]] occur below the dentate (or pectinate) line.<ref name=Day2006 /> They are covered proximally by [[anoderm]] and distally by skin, both of which are sensitive to pain and temperature.<ref name=Beck2011 />

===Differential===
Many anorectal problems, including [[anal fissure|fissures]], [[anal fistula|fistulae]], abscesses, [[colorectal cancer]], [[anorectal varices|rectal varices]], and [[pruritus ani|itching]] have similar symptoms and may be incorrectly referred to as hemorrhoids.<ref name=Review09 /> [[Rectal bleeding]] may also occur owing to colorectal cancer, [[colitis]] including [[inflammatory bowel disease]], [[diverticular disease]], and [[angiodysplasia]].<ref name=NG2011 /> If [[anemia]] is present, other potential causes should be considered.<ref name=Kaidar2007 />

Other conditions that produce an anal mass include [[acrochordon|skin tags]], [[anal warts]], [[rectal prolapse]], [[polyp (medicine)|polyps]], and enlarged anal papillae.<ref name=Kaidar2007 /> [[Anorectal varices]] due to [[portal hypertension]] (blood pressure in the [[portal venous system]]) may present similar to hemorrhoids but are a different condition.<ref name=Kaidar2007 /> Portal hypertension does not increase the risk of hemorrhoids.<ref name=Sun2016 />