Hemorrhoids

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: nonpregnant

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 fiber intake and adequate fluids.[1][13][14]

Consuming 25-30 g of fiber daily is recommended, either with high-fiber foods or with commercial fiber supplements, as well as drinking 6-8 glasses of fluids. 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 fiber 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 (diarrhea and/or constipation), abdominal pain, weight loss, iron-deficiency anemia, or passage of blood clots and/or mucus, lower gastrointestinal endoscopy is performed.

grade 1 hemorrhoids

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

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Consider –

rubber band ligation or sclerotherapy or infrared coagulation

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 hemorrhoids 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 hemorrhoidal 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 hemorrhoidal disease are good.[16] 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 hemorrhoids 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 hemorrhoids that are too small for rubber band ligation.[1]

Sclerotherapy involves injecting a chemical agent directly into the hemorrhoidal 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 hemorrhoidal apex.

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

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

grade 2 prolapsing internal hemorrhoids

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

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Plus –

rubber band ligation or sclerotherapy or infrared coagulation or hemorrhoidal 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 hemorrhoids that are unresponsive to conservative management.[1][13][14] Sclerotherapy, infrared coagulation, or hemorrhoidal arterial ligation can also be used to treat grade 2 hemorrhoids.[1][13][14]

Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant hemorrhoidal 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 hemorrhoidal disease are good.[16] 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 hemorrhoidal tissueKurt G. Davis, MD [Citation ends]. com.bmj.content.model.Caption@1ebd0dfa [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 hemorrhoids that are too small for rubber band ligation (which may include grade 1 to 2 hemorrhoids). 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 hemorrhoid, which causes coagulation, scarring, and subsequent fixation of the internal hemorrhoidal tissue.[1][13]

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

Hemorrhoid artery ligation (also known as transanal hemorrhoidal 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 hemorrhoidal shrinkage). The procedure is commonly done under a short general anesthetic and multiple ligations may be required.[17][18] Patients with grade 2 or 3 hemorrhoids who were randomized to hemorrhoidal arterial ligation experienced fewer recurrences at 1 year than patients treated with rubber band ligation.[19] However, symptom scores and complications did not differ between treatment groups, and patients treated with hemorrhoidal arterial ligation had more early postoperative pain.[19]

grade 3 prolapsing internal hemorrhoids

Plus – rubber band ligation or hemorrhoidal arterial ligation or stapled hemorrhoidopexy

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Plus –

rubber band ligation or hemorrhoidal arterial ligation or stapled hemorrhoidopexy

Treatment recommended for ALL patients in selected patient group

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

Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant hemorrhoidal 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 hemorrhoidal disease are good.[16] Alternatively, rubber bands can be placed at the same time as a colonoscopy.[16] 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 hemorrhoidal tissueKurt G. Davis, MD [Citation ends]. com.bmj.content.model.Caption@231b239 [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 hemorrhoids, rubber band ligation and stapled hemorrhoidopexy (in which prolapsing hemorrhoids 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.[20] Stapled hemorrhoidopexy 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.[20] However, guidelines recommend against routine use of stapled hemorrhoidopexy 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 hemorrhoidopexy.[21][22]

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

Plus – surgical hemorrhoidectomy

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Plus –

surgical hemorrhoidectomy

Treatment recommended for ALL patients in selected patient group

Surgical hemorrhoidectomy is the most effective first-line approach for grade 4 internal hemorrhoids.[13][14] One network meta-analysis that included patients undergoing elective surgery for grade 3 to 4 hemorrhoids found that conventional hemorrhoidectomy was associated with greater postoperative pain but fewer hemorrhoid recurrences than stapled hemorrhoidopexy.[23] A large, open-label pragmatic trial of 777 patients referred to hospital for surgical treatment of hemorrhoids (including grade 4) found that patients who received stapled hemorrhoidopexy had less short-term pain.[25][26] However, recurrence rates, symptoms, reinterventions and quality-of-life measures all favored traditional hemorrhoidectomy.[25][26]

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

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

Early hemorrhoidectomy 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][29]

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 fiber 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 nonoperative approach is recommended during pregnancy, with basic treatment including laxatives, topical treatments, and analgesics.[2][14]

Pregnant and postpartum women have a higher incidence of hemorrhoids, but symptoms typically resolve spontaneously after birth.[30]

Consider – surgical hemorrhoidectomy

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Consider –

surgical hemorrhoidectomy

Treatment recommended for SOME patients in selected patient group

Surgery is rarely an appropriate intervention for pregnant women as hemorrhoidal symptoms often resolve spontaneously after birth, but it may be considered in extreme circumstances.[30][31]

ONGOING

treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, hemorrhoidal arterial ligation, or stapled hemorrhoidopexy

1st line – surgical hemorrhoidectomy

Back

1st line –

surgical hemorrhoidectomy

Surgical hemorrhoidectomy is the best treatment for patients with combined internal and external hemorrhoids or for any patient who has failed conservative treatment options for their internal hemorrhoids. Early hemorrhoidectomy 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][29]

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Hemorrhoids

Treatment algorithm

initial presentation: nonpregnant

dietary and lifestyle modification

rubber band ligation or sclerotherapy or infrared coagulation

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

rubber band ligation or hemorrhoidal arterial ligation or stapled hemorrhoidopexy

surgical hemorrhoidectomy

initial presentation: pregnant

dietary and lifestyle modification

surgical hemorrhoidectomy

treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, hemorrhoidal arterial ligation, or stapled hemorrhoidopexy

surgical hemorrhoidectomy