A new AGA clinical practice update reports that most patients with hemorrhoids can be effectively diagnosed and managed in the office, with dietary measures and minimally invasive procedures forming the backbone of care before surgery is considered.
The expert review, published in Clinical Gastroenterology and Hepatology and based on published literature and specialist consensus, provides 11 best practice advice statements for physicians on diagnosing and treating hemorrhoidal disease, a condition that affects more than 23 million people in the US and accounts for millions of annual visits.
The review's lead author, Waqar Qureshi, MD, of the Division of Gastroenterology at Baylor College of Medicine in Houston, told GI & Hepatology News the release of the update is timely because office-based management of hemorrhoid disease is a relatively recent development. “Incorporating hemorrhoid disease treatment in your practice can save both time and money since surgical referral is unnecessary for the majority of patients presenting with hemorrhoid disease,” Dr. Qureshi said.
Diagnosis and initial evaluation
Hemorrhoids usually present with bleeding, itching, discomfort, or prolapse, with significant pain limited to acutely thrombosed cases or coexisting anal tears. Diagnosis mainly relies on the patient’s history and a physical exam, and internal hemorrhoids are graded by symptoms and degree of prolapse.
The authors recommend performing anoscopy when available for all new patients who may have hemorrhoids to confirm the diagnosis and rule out other conditions, including cancer. A colonoscopy may also be needed in patients with rectal bleeding to check for more serious disease.
First-line therapy: fiber and behavior
Diet and lifestyle changes remain the first-line treatment. Eating more fiber and avoiding straining or sitting on the toilet for long periods can help reduce symptoms like bleeding and prolapse.
Evidence from systematic reviews of seven studies supports fiber supplementation for symptom relief. In one study of 102 patients with advanced disease, limiting toilet time to three minutes and consuming 20–30 grams of fiber daily improved outcomes.
Topical treatments such as anesthetics, corticosteroids, and vasoactive agents may provide short-term relief, but there isn’t much strong evidence that they work well. Steroids should only be used for a short time because they can thin the skin, making it more sensitive.
Office-based procedures dominate
For patients with persistent symptoms, office-based interventions are recommended before surgery.
“Most grades of hemorrhoids can be treated by either a gastroenterologist or a surgeon equally effectively,” Dr. Qureshi said. “In the case of advanced hemorrhoids that do not respond to rubber band ligation, surgery is necessary.”
Rubber band ligation and infrared coagulation are both effective and safe for grades 1–3 hemorrhoids. Rubber band ligation has reported success rates ranging from 66% to 94%, with longer-lasting benefits for prolapse and recurrent bleeding compared with infrared coagulation.
Infrared coagulation, which uses heat to induce fibrosis and reduce blood flow, is particularly useful for smaller internal hemorrhoids and may be preferred in patients at higher bleeding risk, such as those on anticoagulants.
Complications from banding occur in about 2% of cases and include bleeding, urinary retention, and discomfort. “Side effects are rare and minor, except for pelvic sepsis, which is exceedingly rare but important to recognize quickly so that it can be treated promptly,” Dr. Qureshi said.
When to escalate to surgery
The authors recommend surgical referral for patients with grade 3 hemorrhoids who do not respond to office procedures, as well as for those with grade 4 disease. Surgical hemorrhoidectomy remains the definitive treatment for advanced disease, with complication rates of 1% to 2%.
Other surgical options, like stapled hemorrhoidopexy, may cause less pain after surgery but carry higher recurrence and complication risks, so they are used less often.
Special populations
The review highlights tailored management in specific groups. In patients with inflammatory bowel disease, treatment should be delayed until remission due to higher complication risk.
Hemorrhoids occur in up to two-thirds of pregnant women, with conservative therapy preferred during pregnancy and procedural interventions deferred until after delivery unless necessary.
In patients with cirrhosis, distinguishing hemorrhoids from rectal varices is essential. Both banding and infrared coagulation remain viable options, although infrared coagulation may be safer in patients with coagulopathy.
Acute thrombosis and urgent care
Acute thrombosed hemorrhoids, which cause severe pain, are best managed with incision and drainage, which relieves symptoms faster than non-surgical treatments.
The authors noted that their recommendations come from reviewing existing research and expert opinions, not from a formal systematic review or graded evidence. Because of this, the quality and strength of the evidence differ between recommendations, especially for topical treatments and care for special populations.
Dr. Qureshi emphasized one best practice statement from the update that resonates with him: “The diagnosis and treatment of hemorrhoids is within the purview of the gastroenterologist.”
“Hemorrhoid disease is easily and safely managed by the gastroenterologist in the office setting,” he added.
Coauthors were Sook Hoang, MD, Department of Surgery, University of Virginia Health System, Charlottesville; Jeanetta Frye, MD, Division of Gastroenterology, University of Virginia Health System; and Satish Rao, MD, PhD, Division of Gastroenterology/Hepatology, Medical College of Georgia, Augusta.
AGA commissioned the review. Dr. Rao reported consulting for multiple pharmaceutical companies and receiving research support. The other authors had no conflicts of interest to declare.