Guideline sources The following summarized guidelines for the evaluation and management of hemorrhoids are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Gastroenterology (ACG 2021; 2014), the American Society of Colon and Rectal Surgeons (ASCRS 2018), and the American Association of Family Physicians (AAFP 2018). 1 2 3 4 5 Calculator Goligher's classification of inter Guidelines 1. Diagnostic investigations Clinical assessment: As per WSES 2021 guidelines: https://web.pathway.md/diseases/recl7RHiPmqgaSl0E 1/5 6/24/23, 12:31 PM Hemorrhoids Pathway Consider eliciting a focused medical history and performing a complete physical examination, including DRE, to rule out other causes of lower gastrointestinal bleeding in patients with suspected bleeding hemorrhoids. C Consider performing anoscopy as part of the physical examination in patients with complicated hemorrhoids, whenever feasible and well tolerated. C As per ASCRS 2018 guidelines, elicit a disease-specific history and perform a physical examination emphasizing the degree and duration of symptoms and risk factors. B As per ACG 2014 guidelines, elicit history and perform physical examination for the diagnosis of hemorrhoids. B Laboratory tests: consider checking vital signs and obtaining Hgb, hematocrit and coagulation studies to evaluate the severity of bleeding in patients with suspected bleeding hemorrhoids. C Show 2 more Diagnostic imaging: Consider obtaining CT, MRI or endoanal ultrasound in patients with suspected complicated hemorrhoids only if there is suspicion of concomitant anorectal diseases (sepsis/abscess, IBD, neoplasm). C Insufficient evidence to recommend obtaining angiography in patients with complicated hemorrhoids. I 2. Diagnostic procedures Colonoscopy: As per WSES 2021 guidelines, consider performing colonoscopy in patients with complicated hemorrhoids if there is a concern for IBD or cancer arising from patient personal and family history or from physical examination. C As per ASCRS 2018 guidelines, perform complete endoscopic evaluation of the colon in selected patients with symptomatic hemorrhoids and rectal bleeding. B As per ACG 2014 guidelines, perform endoscopy to confirm the source of bleeding in patients with hemorrhoids and rectal bleeding. B 3. Medical management Pharmacotherapy: As per WSES 2021 guidelines, consider offering flavonoids to relieve symptoms in patients with complicated hemorrhoids. C Show 2 more As per ASCRS 2018 guidelines, consider offering medical therapy, representing a heterogeneous group of treatment options, in patients with hemorrhoids with an expectation of minimal harm and a decent potential for relief. C https://web.pathway.md/diseases/recl7RHiPmqgaSl0E 2/5 6/24/23, 12:31 PM Hemorrhoids Pathway 4. Nonpharmacologic interventions Dietary modifications: As per WSES 2021 guidelines, advise dietary and lifestyle modifications (increased fiber and water intake together with adequate bathroom habits) as first-line therapy in patients with complicated hemorrhoids. B As per ACG 2021 guidelines, advise dietary modifications consisting of adequate fluid and fiber intake and minimizing straining at defecation as first-line therapy in patients with symptomatic hemorrhoids. B As per AAFP 2018 guidelines, advise increasing fiber intake as an effective first-line, non- surgical treatment in patients with hemorrhoids. A As per ASCRS 2018 guidelines, advise dietary modifications consisting of adequate fluid and fiber intake and counsel regarding defecation habits as the primary first-line therapy in patients with symptomatic hemorrhoid disease. B 5. Therapeutic procedures Office-based procedures: As per WSES 2021 guidelines, insufficient evidence to recommend performing office-based procedures (rubber band ligation, sclerotherapy, infrared coagulation) in patients with complicated hemorrhoids. I As per ACG 2021 guidelines, perform office-based procedures, such as a rubber band ligation or infrared coagulation, sclerotherapy, and bipolar coagulation as alternatives, in patients with symptomatic grade I-II internal hemorrhoids failed medical therapy. B Updated evidence: MoLish In patients with symptomatic hemorrhoids, modified ligation procedure was superior to stapled hemorrhoidectomy with respect to cure rate at 6 months. Haibo Yang et al. BJS Open. 2022 May 2. As per AAFP 2018 guidelines, consider performing rubber band ligation as the preferred office- based procedure in patients with grade I-III hemorrhoids. B As per ASCRS 2018 guidelines, consider performing office-based procedures, such as banding, sclerotherapy, and infrared coagulation, in patients with grade I and II and selected patients with grade III internal hemorrhoids failed medical treatment. Recognize that hemorrhoid banding is typically the most effective option. B 6. Surgical interventions https://web.pathway.md/diseases/recl7RHiPmqgaSl0E 3/5 6/24/23, 12:31 PM Hemorrhoids Pathway Early excision of thrombosed external hemorrhoids: As per WSES 2021 guidelines: Decide between nonoperative management and early surgical excision in patients with thrombosed hemorrhoids based on local expertise and patient's preference. B Avoid performing incision and drainage of the thrombus in patients with thrombosed hemorrhoids. D As per ACG 2021 guidelines, perform either surgical excision or incision and evacuation of the thrombus in patients with acutely thrombosed external hemorrhoids if seen within the first 4 days. B As per AAFP 2018 guidelines, perform surgical excision of thrombosed hemorrhoids in most patients presenting within 2-3 days of symptom onset. B As per ASCRS 2018 guidelines, consider performing early surgical excision in selected patients with thrombosed external hemorrhoids. C Excisional hemorrhoidectomy: As per ACG 2021 guidelines, consider performing excisional hemorrhoidectomy in patients with symptomatic grade III hemorrhoids. C As per AAFP 2018 guidelines: Perform excisional (conventional) hemorrhoidectomy for the treatment of patients with grade III-IV, recurrent, or highly symptomatic hemorrhoids. A Recognize that the use of LigaSure during conventional hemorrhoidectomy leads to decreased pain in the immediate postoperative period. A As per ASCRS 2018 guidelines: Perform hemorrhoidectomy typically in patients with symptoms resulting from external hemorrhoids or combined internal and external hemorrhoids with prolapse (grade III-IV). A Prescribe a multimodality pain regimen in patients undergoing surgical hemorrhoidectomy to reduce narcotic usage and promote a faster recovery. B Stapled hemorrhoidopexy: recognize that stapled hemorrhoidopexy results in more frequent recurrence of symptoms and prolapse than conventional hemorrhoidectomy. A Hemorrhoidal artery ligation: As per ACG 2021 guidelines, consider performing Doppler-guided procedures such as hemorrhoidal artery ligations in patients with symptomatic grade III hemorrhoids. C As per AAFP 2018 guidelines, recognize that hemorrhoidal artery ligation is an emerging therapy with early outcomes similar to conventional hemorrhoidectomy in patients with grade II- III hemorrhoids. B References 1. 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 3 284 292. https://web.pathway.md/diseases/recl7RHiPmqgaSl0E 4/5 6/24/23, 12:31 PM Hemorrhoids Pathway Open 2. Antonio Tarasconi, Gennaro Perrone, Justin Davies et al. Anorectal emergencies: WSES AAST guidelines. World J Emerg Surg. 2021 Sep 16;16 1 48. Open 3. Arnold Wald, Adil E Bharucha, Berkeley Limketkai et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021 Oct 1;116 10 1987 2008. Open 4. Timothy Mott, Kelly Latimer, Chad Edwards. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician. 2018 Feb 1;97 3 172 179. Open 5. Wald A, Bharucha AE, Cosman BC et al. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014 Aug;109 8 1141 57. Open 6. Robert S Sandler, Anne F Peery. Rethinking What We Know About Hemorrhoids. Clin Gastroenterol Hepatol. 2019 Jan;17 1 8 15. Open 7. Varut Lohsiriwat. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012 May 7;18 17 2009 17. Open 8. Anne F Peery, Robert S Sandler, Joseph A Galanko et al. Risk Factors for Hemorrhoids on Screening Colonoscopy. PLoS One. 2015 Sep 25;10 9):e0139100. Open 9. R M Kluiber, B G Wolff. Evaluation of anemia caused by hemorrhoidal bleeding. Dis Colon Rectum. 1994 Oct;37 10 1006 7. Open 10. Haibo Yang, Zhan Shi, Wei Chen et al. Modified ligation procedure for prolapsed haemorrhoids versus stapled haemorrhoidectomy for the management of symptomatic haemorrhoids MoLish): randomized clinical trial. BJS Open. 2022 May 2;6 3):zrac064. Open https://web.pathway.md/diseases/recl7RHiPmqgaSl0E 5/5