Hemorrhoids Guidelines

Updated: May 31, 2022
  • Author: Kyle R Perry, MD; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Guidelines Summary

Treatment guidelines are available from the American Gastroenterological Association (AGA), [21] the American Society of Colon and Rectal Surgeons (ASCRS), [14, 22, 23] the American College of Gastroenterology (ACG), [17, 18, 23] and the World Society of Emergency Surgery and American Association for the Surgery of Trauma (WSES-AAST). [19]

The ACG and ASCRS guidelines, for example, recommend that patients with symptomatic hemorrhoids initially be treated with increased fiber and adequate fluid intake, [14, 17, 23] Patients should be referred for surgery if they are refractory to or unable to tolerate office procedures, if their hemorrhoids are accompanied by large symptomatic external tags, or if they have either fourth-degree or large third-degree hemorrhoids. [23]

ACG strongly recommends patients with acute thrombosed external hemorrhoids that are seen within the first 4 days may benefit from either surgical excision or incision and evacuation of the thrombus. [17] For symptomatic grade 3 hemorrhoids, it is suggested that Doppler-guided procedures (eg, hemorrhoidal artery ligations) have similar outcomes to hemorrhoidectomy. [17]

The ASCRS notes that office-based procedures (eg, banding, sclerotherapy, infrared coagulation) can be effective for most cases of grade I and II hemorrhoids and select cases of refractory grade III internal hemorrhoidal disease. [14] It also indicates clinicians should typically offer hemorrhoidectomy to patients with symptomatic disease from external hemorrhoids or combined internal/external hemorrhoids with prolapse. For those who undergo surgical hemorrhoidectomy, a multimodality pain regimen is recommended to reduce use of narcotics and promote a faster recovery. [14]

The AAFP also recommends increasing fiber intake as an effective first-line, nonsurgical treatment. [18] Symptomatic relief may be achieved in those who undergo excision of thrombosed hemorrhoids within 2-3 days of symptom onset. For office-based treatment of grades I-III hemorrhoids, rubber band ligation is preferred, whereas excisional (conventional) hemorrhoidectomy is effective for grades IV or V, recurrent, or highly symptomatic hemorrhoids. Ligasure use during conventional hemorrhoidectomy reduces pain in the immediate postoperative period. Outcomes of stapled hemorrhoidopexy include more frequent symptomatic recurrence and prolapse than that from conventional hemorrhoidectomy. [18]

The WSES-AAST guidelines recommend a topical muscle relaxant for patients with thrombosed or strangulated hemorrhoids. In patients who have anorectal varices and severe bleeding, it is recommended to maintain an Hb level of at least >7 g/dL (4.5 mmol/L) during the resuscitation phase and a mean arterial pressure >65 mm Hg, but avoid fluid overload. [19]