Highlights & Basics
- Hemorrhoids are vascular-rich connective tissue cushions located within the anal canal. Internal hemorrhoids lie proximal to the dentate line in the anal canal; external hemorrhoids are located distal to the dentate line.
- Hemorrhoidal disease presents as painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass.
- Diagnosis is confirmed with visualization of the protruding tissue or anoscopic visualization.
- Treatment for all patients includes increasing dietary fiber. Rubber band ligation is a reasonable first-line treatment choice for grade 2 and 3 internal hemorrhoids. Other treatment options for grade 2 or 3 hemorrhoids include sclerotherapy, infrared coagulation, hemorrhoid arterial ligation, or stapled hemorrhoidopexy. Surgical hemorrhoidectomy may be considered for patients with large grade 3 hemorrhoids, but it is typically reserved for patients with grade 4 hemorrhoids.
- Complications include recurrence or worsening of symptoms, excessive bleeding, nonreducible prolapse, and, rarely, pelvic sepsis.
Quick Reference
History & Exam
Key Factors
rectal bleeding
intermittent protrusion
perianal pain/discomfort
Other Factors
anal pruritus
tender palpable perianal lesion
anal mass
Diagnostics Tests
1st Tests to Order
anoscopic exam
colonoscopy/flexible sigmoidoscopy
CBC
stool for occult heme
Treatment Options
acute
all patients at presentation
all patients at presentation
grade 1 hemorrhoids
grade 2 prolapsing internal hemorrhoids
grade 3 prolapsing internal hemorrhoids
grade 4 internal, external, or mixed internal and external hemorrhoids
Definition
Classifications
External hemorrhoids
Internal hemorrhoids (grade 1-4)
- Grade 1 - protrusion is limited to within the anal canal.
- Grade 2 - protrudes beyond the anal canal but spontaneously reduces on cessation of straining.
- Grade 3 - protrudes outside the anal canal and reduces fully on manual pressure.
- Grade 4 - protrudes outside the anal canal and is irreducible.
Vignette
Common Vignette 1
Common Vignette 2
Other Presentations
Epidemiology
Etiology
Pathophysiology
Images
Diagnostic Approach
Physical exam
Endoscopy
Laboratory
Risk Factors
History & Exam
Tests
Differential Diagnosis
Anal fissure
Differentiating Signs/Symptoms
- Anal fissures are associated with painful bleeding on defecation and possibly a sentinel skin tag (sometimes reported by the patient as a "painful hemorrhoid"). Fissures are seen as linear tears in the anal mucosae, most commonly in the posterior midline of the anal canal.
Differentiating Tests
- Physical exam.
Crohn disease
Differentiating Signs/Symptoms
- Crohn disease affecting the large bowel can present with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.
Differentiating Tests
- Endoscopy findings highly variable, depending on disease activity. Characteristically shows "skip areas" with areas of disease with intervening areas of normal mucosa. Usually most severe in the cecum and right colon, with rectum often spared.
Ulcerative colitis
Differentiating Signs/Symptoms
- Ulcerative colitis commonly presents with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.
Differentiating Tests
- Endoscopy reveals diffuse inflammation and ulceration in cases of acute ulcerative colitis.
Colorectal cancer
Differentiating Signs/Symptoms
- History of altered bowel habit (diarrhea and/or constipation), abdominal pain, weight loss, iron-deficiency anemia, colonic polyps, and positive family history suggest colorectal cancer.
Differentiating Tests
- Endoscopy may reveal mass, stricture, and obstruction. Blood tests commonly reveal anemia.
Differentiating Signs/Symptoms
- Commonly bleeding with a history of a preceding abscess, with continued intermittent bloody/purulent drainage. Visualized as a punctate opening on the anal margin adjacent to the anal canal.
Differentiating Tests
- Physical exam.
Differentiating Signs/Symptoms
- Usually presents as protruding mass per rectum especially with straining. May be associated with mucus or blood-stained discharge, pain, and or fecal incontinence.
Differentiating Tests
- Physical exam. A defecogram may help distinguish between mucosal prolapse and a full thickness rectal prolapse. Examination under anesthesia may be required to confirm and assess severity.
Treatment Approach
Mild intermittent bleeding
Internal hemorrhoids
External or combined internal and external hemorrhoids
Treatment Options
all patients at presentation
dietary and lifestyle modification
Comments
- 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.[24] Oral laxatives such as polyethylene glycol or docusate sodium may be given to patients who are unable to increase their dietary fiber intake.[1] [2] [10]
- 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
sclerotherapy or infrared coagulation
Comments
- 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.
- Both sclerotherapy and infrared coagulation are office procedures and do not require anesthesia.
grade 2 prolapsing internal hemorrhoids
rubber band ligation or sclerotherapy or infrared coagulation or hemorrhoid arterial ligation or stapled hemorrhoidopexy
Comments
- 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] [2] [10] Sclerotherapy, infrared coagulation, hemorrhoid arterial ligation, and stapled hemorrhoidopexy can also be used to treat grade 2 hemorrhoids.[1] [2] [10]
- Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant hemorrhoidal tissue, with care being 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.[25] Patients can experience transient bleeding or, extremely rarely, septic events. Anticoagulant medications should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.Images
- 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.
- 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.[12] [13] Patients with grade 2 or 3 hemorrhoids who were randomized to hemorrhoid arterial ligation experienced fewer recurrences at 1 year than patients treated with rubber band ligation.[14] However, symptom scores and complications did not differ between treatment groups, and patients treated with hemorrhoid arterial ligation had more early postoperative pain.[14]
grade 3 prolapsing internal hemorrhoids
rubber band ligation or hemorrhoid arterial ligation or stapled hemorrhoidopexy
Comments
- Rubber band ligation remains a reasonable choice for grade 3 hemorrhoids.[1] [2] [10] 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] [2]
- Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant hemorrhoidal tissue,with care being 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.[25] Alternatively, rubber bands can be placed at the same time as a colonoscopy.[25] Anticoagulant medications should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.Images
- 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.[15] 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.[15] Patients should be informed of the potential for symptomatic recurrence following stapled hemorrhoidopexy.[16] [17]
grade 4 internal, external, or mixed internal and external hemorrhoids
surgical hemorrhoidectomy
Comments
- Surgical hemorrhoidectomy is the most effective first-line approach for grade 4 internal hemorrhoids. 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.[18] 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.[20] [21] However, recurrence rates, symptoms, reinterventions and quality-of-life measures all favored traditional hemorrhoidectomy.[20] [21]
- 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.
- 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.[2]
treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, transanal hemorrhoidal dearterialization, or stapled hemorrhoidopexy
surgical hemorrhoidectomy
Comments
- 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. 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.[2]
Emerging Tx
Electrotherapy
Prevention
Primary Prevention
Secondary Prevention
Follow-Up Overview
Prognosis
Recurrence
Monitoring
Complications
Citations
Wald A, Bharucha AE, Limketkai B, et al. ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1;116(10):1987-2008.[Abstract][Full Text]
Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum. 2018 Mar;61(3):284-92.[Abstract][Full Text]
van Tol RR, Kleijnen J, Watson AJM, et al. European Society of Coloproctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020 Jun;22(6):650-62.[Abstract]
Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005034.[Abstract][Full Text]
Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005034.[Abstract][Full Text]
1. Wald A, Bharucha AE, Limketkai B, et al. ACG clinical guidelines: management of benign anorectal disorders. Am J Gastroenterol. 2021 Oct 1;116(10):1987-2008.[Abstract][Full Text]
2. Davis BR, Lee-Kong SA, Migaly J, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum. 2018 Mar;61(3):284-92.[Abstract][Full Text]
3. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology. 1990 Feb;98(2):380-6.[Abstract]
4. Johanson JF, Sonnenberg A. Temporal changes in the occurrence of hemorrhoids in the United States and England. Dis Colon Rectum. 1991 Jul;34(7):585-91.[Abstract]
5. Thomson WH. The nature of haemorrhoids. Br J Surg. 1975 Jul;62(7):542-52.[Abstract]
6. Haas PA, Fox TA Jr, Haas GP. The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984 Jul;27(7):442-50.[Abstract]
7. Saleeby RG Jr, Rosen L, Stasik JJ, et al. Hemorrhoidectomy during pregnancy: risk or relief? Dis Colon Rectum. 1991 Mar;34(3):260-1.[Abstract]
8. Hosking SW, Smart HL, Johnson AG, et al. Anorectal varices, haemorrhoids, and portal hypertension. Lancet. 1989 Feb 18;1(8634):349-52.[Abstract]
9. Moesgaard F, Nielsen ML, Hansen JB, et al. High fiber diet reducing bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum. 1982 Jul-Aug;25(5):454-6.[Abstract]
10. van Tol RR, Kleijnen J, Watson AJM, et al. European Society of Coloproctology: guideline for haemorrhoidal disease. Colorectal Dis. 2020 Jun;22(6):650-62.[Abstract]
11. ASGE Technology Committee; Appalaneni V, Fanelli RD, Sharaf RN, et al. The role of endoscopy in patients with anorectal disorders. Gastrointest Endosc. 2010 Dec;72(6):1117-23.[Abstract][Full Text]
12. Giordano P, Overton J, Madeddu F, et al. Transanal hemorrhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009 Sep;52(9):1665-71.[Abstract]
13. Wallis de Vries BM, van der Beek ES, de Wijkerslooth LR, et al. Treatment of grade 2 and 3 hemorrhoids with Doppler-guided hemorrhoidal artery ligation. Dig Surg. 2007;24(6):436-40.[Abstract][Full Text]
14. Brown S, Tiernan J, Biggs, et al. The HubBLe Trial: haemorrhoidal artery ligation (HAL) versus rubber band ligation (RBL) for symptomatic second- and third-degree haemorrhoids: a multicentre randomised controlled trial and health-economic evaluation. Health Technol Assess. 2016 Nov;20(88):1-150.[Abstract][Full Text]
15. Peng BC, Jayne DG, Ho YH. Randomized trial of rubber band ligation vs. stapled hemorrhoidectomy for prolapsed piles. Dis Colon Rectum. 2003 Mar;46(3):291-7.[Abstract]
16. Acheson AG, Scholefield JH. Management of haemorrhoids. BMJ. 2008 Feb 16;336(7640):380-3.[Abstract]
17. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD005393.[Abstract][Full Text]
18. Simillis C, Thoukididou SN, Slesser AA, et al. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015 Dec;102(13):1603-18.[Abstract]
19. Du T, Quan S, Dong T, et al. Comparison of surgical procedures implemented in recent years for patients with grade III and IV hemorrhoids: a network meta-analysis. Int J Colorectal Dis. 2019 Jun;34(6):1001-12.[Abstract][Full Text]
20. Watson AJ, Hudson J, Wood J, et al. Comparison of stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease (eTHoS): a pragmatic, multicentre, randomised controlled trial. Lancet. 2016 Nov 12;388(10058):2375-85.[Abstract]
21. Watson AJ, Cook J, Hudson J, et al. A pragmatic multicentre randomised controlled trial comparing stapled haemorrhoidopexy with traditional excisional surgery for haemorrhoidal disease: the eTHoS study. Health Technol Assess. 2017 Nov;21(70):1-224.[Abstract][Full Text]
22. Xu L, Chen H, Gu Y. Stapled hemorrhoidectomy versus transanal hemorrhoidal dearterialization in the treatment of hemorrhoids: an updated meta-analysis. Surg Laparosc Endosc Percutan Tech. 2019 Apr;29(2):75-81.[Abstract][Full Text]
23. Emile SH, Elfeki H, Sakr A, et al. Transanal hemorrhoidal dearterialization (THD) versus stapled hemorrhoidopexy (SH) in treatment of internal hemorrhoids: a systematic review and meta-analysis of randomized clinical trials. Int J Colorectal Dis. 2019 Jan;34(1):1-11.[Abstract][Full Text]
24. Moesgaard F, Nielsen ML, Hansen JB, et al. High fiber diet reducing bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum. 1982 Jul-Aug;25(5):454-6.[Abstract]
25. Wrobleski DE, Corman ML, Veidenheimer MC, et al. Long-term evaluation of rubber ring ligation in hemorrhoidal disease. Dis Colon Rectum. 1980 Oct;23(7):478-82.[Abstract]
26. National Institute for Health and Care Excellence. Electrotherapy for the treatment of haemorrhoids Interventional procedures guidance. Jun 2015 [internet publication].[Full Text]
27. Australian Department of Health. Pregnancy Care Guidelines. Part I: Common conditions during pregnancy. 2019 [internet publication].[Full Text]
28. Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005034.[Abstract][Full Text]
29. Kluiber RM, Wolff BG. Evaluation of anemia caused by hemorrhoidal bleeding. Dis Colon Rectum. 1994 Oct;37(10):1006-7.[Abstract]
30. Greenspon J, Williams SB, Young HA, et al. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum. 2004 Sep;47(9):1493-8.[Abstract]
31. Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD005034.[Abstract][Full Text]
32. Lyons NJR, Cornille JB, Pathak S, et al. Systematic review and meta-analysis of the role of metronidazole in post-haemorrhoidectomy pain relief. Colorectal Dis. 2017 Sep;19(9):803-11.[Abstract]
Key Articles
Referenced Articles
Guidelines
Diagnostic
Summary
Diagnosis is clinical. Medical history is followed by a focused medical examination, emphasizing degree and duration of symptoms. In patients with symptomatic hemorrhoids and rectal bleeding, endoscopic evaluation of the colon is indicated.Published by
American Society of Colon and Rectal Surgeons
Published
2018
Summary
Diagnosis is by history and physical exam, and typically requires exclusion of other conditions that can present with similar symptoms.Published by
American College of Gastroenterology
Published
2021
Summary
Presenting symptoms include rectal pain, itching, prolapse, and bleeding. Diagnosis is made by inspection of the perineum, digital rectal examination, and anoscopy. Endoscopic evaluation for colorectal cancer should be performed depending on the clinical situation.Published by
American Society for Gastrointestinal Endoscopy
Published
2010
Summary
Diagnosis is based on clinical history and exclusion of other diseases, including colorectal cancer and inflammatory bowel disease, by examination of the anorectal region.Published by
European Society of Coloproctology
Published
2020
Treatment
Summary
Adequate fluid and fiber intake and counseling are first-line therapy for symptomatic hemorrhoids. Patients with grade 1 and 2 (and select patients with grade 3) internal hemorrhoids can be effectively treated with banding, sclerotherapy, and infrared coagulation; banding is typically the most effective option. Surgical hemorrhoidectomy is the best treatment for patients with combined internal and external hemorrhoids or for any patient who has failed more conservative treatment options.Published by
American Society of Colon and Rectal Surgeons
Published
2018
Summary
Increased fiber and adequate fluid intake are first-line treatment options for symptomatic hemorrhoids.Published by
American College of Gastroenterology
Published
2014
Summary
Medical management suffices for most patients with symptomatic internal hemorrhoids. Rubber band ligation is effective and can be performed with either flexible or rigid endoscopes. Surgical treatments are preferred for all fourth-degree hemorrhoids.Published by
American Society for Gastrointestinal Endoscopy
Published
2010
Summary
The guidelines provide a reliable and standard reference for health professionals providing antenatal care. By providing a summary of the currently available evidence on many aspects of antenatal care, including hemorrhoids, they aim to promote consistency of care and improve the experience and outcomes of pregnancy care for all families.Published by
Australian Department of Health
Published
2019
Summary
Guidance on the most effective (surgical) treatment and management of patients with hemorrhoidal disease.Published by
European Society of Coloproctology
Published
2020