Haemorrhoids

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

initial presentation: non-pregnant

1st line – dietary and lifestyle modification

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1st line –

dietary and lifestyle modification

All patients should be offered information about lifestyle and dietary modification, specifically increased fibre intake and adequate fluids.[1][13][14]

Consuming 25-30 g of fibre daily is recommended, either with high-fibre foods or with commercial fibre supplements, as well as drinking 6-8 glasses of fluids.[1] These measures alone may be all that is necessary for those patients with mild symptoms.[12] Oral laxatives such as polyethylene glycol or docusate sodium may be given to patients who are unable to increase their dietary fibre intake.[1][14] Other basic treatments may include topical treatments and analgesics.[14]

Straining or spending excessive time at stool should be discouraged.[1][13][14] Moist, gentle cleaning following a bowel movement is advised.

In the presence of suspicious symptoms, such as altered bowel habit (diarrhoea and/or constipation), abdominal pain, weight loss, iron-deficiency anaemia, or passage of blood clots and/or mucus, lower gastrointestinal endoscopy is performed.

grade 1 haemorrhoids

Consider – rubber band ligation or sclerotherapy or infrared coagulation

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Consider –

rubber band ligation or sclerotherapy or infrared coagulation

Additional treatment recommended for SOME patients in selected patient group

Rubber band ligation is a simple and effective method of managing excess tissue and is the treatment of choice for grade 1 haemorrhoids that are unresponsive to conservative management.[1][13][14] Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant haemorrhoidal tissue, with care taken to place the bands above the dentate line. The tissue contained in the band necroses and sloughs in approximately 1 week; success rates for controlling haemorrhoidal disease are good.[15] Patients can experience transient bleeding or, extremely rarely, septic events. Anticoagulants should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.

Sclerotherapy and infrared coagulation can also be performed if grade 1 haemorrhoids are unresponsive to conservative management.[1][13][14] Both have similar effects and may require multiple treatment sessions to successfully ablate the tissue.[1][13] Sclerotherapy and infrared coagulation may be more suitable for haemorrhoids that are too small for rubber band ligation.[1]

Sclerotherapy involves injecting a chemical agent directly into the haemorrhoidal tissue to cause local tissue destruction and scarring. With the aid of an anoscope, 2-3 mL of a sclerosant (5% phenol, 5% quinine or urea) is injected into the submucosa of the haemorrhoidal apex.

Infrared coagulation uses infrared radiation applied directly to the haemorrhoid, which causes coagulation, scarring, and subsequent fixation of the internal haemorrhoidal tissue.[1][13]

Both sclerotherapy and infrared coagulation are office procedures and do not require anaesthesia.

grade 2 prolapsing internal haemorrhoids

Plus – rubber band ligation or sclerotherapy or infrared coagulation or haemorrhoidal arterial ligation

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Plus –

rubber band ligation or sclerotherapy or infrared coagulation or haemorrhoidal arterial ligation

Treatment recommended for ALL patients in selected patient group

Rubber band ligation is a simple and effective method of managing excess tissue and is the treatment of choice for grade 2 haemorrhoids that are unresponsive to conservative management.[1][13][14] Sclerotherapy, infrared coagulation, or haemorrhoidal arterial ligation can also be used to treat grade 2 haemorrhoids.[1][13][14]

Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant haemorrhoidal tissue, with care taken to place the bands above the dentate line. The tissue contained in the band necroses and sloughs in approximately 1 week; success rates for controlling haemorrhoidal disease are good.[15] Patients can experience transient bleeding or, extremely rarely, septic events. Anticoagulants should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.[Figure caption and citation for the preceding image starts]: Rubber band on redundant haemorrhoidal tissueKurt G. Davis, MD [Citation ends]. com.bmj.content.model.Caption@3dba8af0 [Figure caption and citation for the preceding image starts]: Bands placed above the dentate lineKurt G. Davis, MD [Citation ends].[Figure caption and citation for the preceding image starts]: AnoscopeKurt G. Davis, MD [Citation ends].

Sclerotherapy and infrared coagulation may be more suitable for haemorrhoids that are too small for rubber band ligation (which may include grade 1 to 2 haemorrhoids). Both have similar effects and may require multiple treatment sessions to successfully ablate the tissue.[1][13]

Infrared coagulation uses infrared radiation applied directly to the haemorrhoid, which causes coagulation, scarring, and subsequent fixation of the internal haemorrhoidal tissue.[1][13]

Both sclerotherapy and infrared coagulation are office procedures and do not require anaesthesia.

Haemorrhoid artery ligation (also known as transanal haemorrhoidal de-arterialisation) uses a custom-designed proctoscope coupled with a Doppler transducer to identify and ligate the terminal branches of superior rectal artery above the dentate line (resulting in haemorrhoidal shrinkage). The procedure is commonly done under a short general anaesthetic and multiple ligations may be required.[16][17] Patients with grade 2 or 3 haemorrhoids who were randomised to haemorrhoidal arterial ligation experienced fewer recurrences at 1 year than patients treated with rubber band ligation.[18] However, symptom scores and complications did not differ between treatment groups, and patients treated with haemorrhoidal arterial ligation had more early postoperative pain.[18]

grade 3 prolapsing internal haemorrhoids

Plus – rubber band ligation or haemorrhoidal arterial ligation or stapled haemorrhoidopexy

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Plus –

rubber band ligation or haemorrhoidal arterial ligation or stapled haemorrhoidopexy

Treatment recommended for ALL patients in selected patient group

Rubber band ligation remains a reasonable choice for grade 3 haemorrhoids.[1][13][14] However, patients with large grade 3 haemorrhoids (in addition to patients refractory to or who cannot tolerate outpatient procedures; patients with large, symptomatic external tags; or patients with grade 4 haemorrhoids) are candidates for surgery (haemorrhoidectomy, stapled haemorrhoidopexy, haemorrhoid artery ligation).[1][13]

Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant haemorrhoidal tissue, with care taken to place the bands above the dentate line. The tissue contained in the band necroses and sloughs in approximately 1 week; success rates for controlling haemorrhoidal disease are good.[15] Alternatively, rubber bands can be placed at the same time as a colonoscopy.[15] Patients can experience transient bleeding or, extremely rarely, septic events. Anticoagulants should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.[Figure caption and citation for the preceding image starts]: Rubber band on redundant haemorrhoidal tissueKurt G. Davis, MD [Citation ends]. com.bmj.content.model.Caption@79f0d7a2 [Figure caption and citation for the preceding image starts]: Bands placed above the dentate lineKurt G. Davis, MD [Citation ends].[Figure caption and citation for the preceding image starts]: AnoscopeKurt G. Davis, MD [Citation ends].

In a small study of patients with grade 3 or small grade 4 haemorrhoids, rubber band ligation and stapled haemorrhoidopexy (in which prolapsing haemorrhoids are relocated within the anal canal, rather than excised) were equally effective in controlling symptomatic prolapse, but rubber band ligation was associated with an increased risk of recurrent bleeding.[19] Stapled haemorrhoidopexy was associated with increased pain and analgesia use at 2-week and at 2-month follow-up; the two treatment groups did not differ with respect to patient satisfaction or quality of life.[19] However, guidelines recommend against routine use of stapled haemorrhoidopexy as a first-line surgical option due to an increased risk of complications and recurrence.[1][13] Patients should be informed of the potential for symptomatic recurrence following stapled haemorrhoidopexy.[20][21]

grade 4 internal, external, or mixed internal and external haemorrhoids

Plus – surgical haemorrhoidectomy

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Plus –

surgical haemorrhoidectomy

Treatment recommended for ALL patients in selected patient group

Surgical haemorrhoidectomy is the most effective first-line approach for grade 4 internal haemorrhoids.[13][14] One network meta-analysis that included patients undergoing elective surgery for grade 3 to 4 haemorrhoids found that conventional haemorrhoidectomy was associated with greater postoperative pain but fewer haemorrhoid recurrences than stapled haemorrhoidopexy.[22] A large, open-label pragmatic trial of 777 patients referred to hospital for surgical treatment of haemorrhoids (including grade 4) found that patients who received stapled haemorrhoidopexy had less short-term pain.[24][25] However, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured traditional haemorrhoidectomy.[24][25]

For external haemorrhoids, or combined internal and external haemorrhoids with severe symptoms, surgical excision may be the only effective treatment option. This involves excision under either a general or regional anaesthetic. Asymptomatic external haemorrhoids do not warrant invasive treatment but may be observed while the patient follows dietary and lifestyle modification.

In thrombosis of external haemorrhoids, minimally invasive procedures such as de-roofing may be required for symptom relief, which can be done under topical, regional, or general anaesthetic.

Early haemorrhoidectomy is likely to increase speed of symptom resolution, reduce the chance of recurrence, and provide longer periods of remission compared to conservative management alone.[1][13][28]

initial presentation: pregnant

1st line – dietary and lifestyle modification

Back

1st line –

dietary and lifestyle modification

All patients should be offered information about lifestyle and dietary modification, specifically increased fibre intake, adequate fluids, and not straining or spending excessive time sitting at stool.[1][13][14] Moist, gentle cleaning following a bowel movement is advised. These measures alone may be all that is necessary for those patients with mild symptoms.[12]

A non-operative approach is recommended during pregnancy, with basic treatment including laxatives, topical treatments, and analgesics.[2][14]

Pregnant and postnatal women have a higher incidence of haemorrhoids, but symptoms typically resolve spontaneously after birth.[29]

Consider – surgical haemorrhoidectomy

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Consider –

surgical haemorrhoidectomy

Additional treatment recommended for SOME patients in selected patient group

Surgery is rarely an appropriate intervention for pregnant women as haemorrhoidal symptoms often resolve spontaneously after birth, but it may be considered in extreme circumstances.[29][30]

ONGOING

treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, haemorrhoidal arterial ligation, or stapled haemorrhoidopexy

1st line – surgical haemorrhoidectomy

Back

1st line –

surgical haemorrhoidectomy

Surgical haemorrhoidectomy is the best treatment for patients with combined internal and external haemorrhoids or for any patient who has failed conservative treatment options for their internal haemorrhoids. Early haemorrhoidectomy is likely to increase speed of symptom resolution, reduce the chance of recurrence, and provide longer periods of remission compared to conservative management alone.[1][13][28]

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Haemorrhoids

Treatment algorithm

initial presentation: non-pregnant

dietary and lifestyle modification

rubber band ligation or sclerotherapy or infrared coagulation

rubber band ligation or sclerotherapy or infrared coagulation or haemorrhoidal arterial ligation

rubber band ligation or haemorrhoidal arterial ligation or stapled haemorrhoidopexy

surgical haemorrhoidectomy

initial presentation: pregnant

dietary and lifestyle modification

surgical haemorrhoidectomy

treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, haemorrhoidal arterial ligation, or stapled haemorrhoidopexy

surgical haemorrhoidectomy