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]

Medication

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Media Gallery

Hemorrhoids. Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.
Hemorrhoids. Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of a clot.

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Author

Kyle R Perry, MD Emergency Physician, The Queen's Medical Center; Volunteer Faculty, University of Hawaii, John A Burns School of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

William G Gossman, MD, FAAEM Associate Clinical Professor of Emergency Medicine, Creighton University School of Medicine; Chairman, Department of Emergency Medicine, Creighton University Medical Center

William G Gossman, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, MSc, DSc, AGAF Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, Professor, Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow; Fellow of the Royal Society of Medicine

John Geibel, MD, MSc, DSc, AGAF is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, Society for Surgery of the Alimentary Tract

Disclosure: Nothing to disclose.

Additional Contributors

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Scott C Thornton, MD Associate Clinical Professor of Surgery, Yale University School of Medicine; Director, Colorectal Teaching, Bridgeport Hospital; Private Practice, Park Avenue Surgical Associates

Scott C Thornton, MD is a member of the following medical societies: American Society of Colon and Rectal Surgeons

Disclosure: Nothing to disclose.

Adam J Rosh, MD Assistant Professor, Program Director, Emergency Medicine Residency, Department of Emergency Medicine, Detroit Receiving Hospital, Wayne State University School of Medicine

Adam J Rosh, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors David R Gurley, MD, Richard Sinert, DO, and Pilar Guerrero, MD,to the development and writing of a source article.

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