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
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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]
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