From the Guidelines
Bleeding hemorrhoids should be treated with non-operative management as the first-line therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, as well as adequate bathroom habits, as recommended by the most recent guidelines 1. This approach is based on moderate quality evidence and is considered a strong recommendation. The guidelines suggest that patients with complicated hemorrhoids, including those with bleeding, should start with non-operative management, which includes dietary and lifestyle modifications, before considering other treatment options.
Some key lifestyle changes that can help manage bleeding hemorrhoids include:
- Increasing fiber intake to 25-30 grams daily through foods or supplements like psyllium (Metamucil, 1 tablespoon in water 1-3 times daily) 1
- Drinking 6-8 glasses of water daily to soften stools 1
- Practicing adequate bathroom habits, such as avoiding straining and prolonged sitting 1
- Considering the use of flavonoids to relieve symptoms, although the evidence for this is moderate and the recommendation is weak 1
It's essential to note that the literature regarding office-based procedures, such as rubber band ligation, sclerotherapy, and infrared coagulation, is heterogeneous and of low quality, making it difficult to recommend these procedures for complicated hemorrhoids, including bleeding ones 1. Similarly, there is no clear recommendation for the use of surgery in patients with bleeding hemorrhoids, although surgical excision may be considered for thrombosed hemorrhoids based on local expertise and patient preference 1.
In terms of pharmacological management, the guidelines suggest that flavonoids may be used to relieve symptoms, although the evidence is moderate and the recommendation is weak 1. There is no recommendation for the use of NSAIDs, topical steroids, or other topical agents for complicated hemorrhoids, including bleeding ones 1.
Overall, the management of bleeding hemorrhoids should prioritize non-operative management, focusing on dietary and lifestyle changes, with other treatment options considered on a case-by-case basis, taking into account the individual patient's needs and preferences, as well as the available evidence and guidelines 1.
From the Research
Treatment Options for Bleeding Hemorrhoids
- Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for bleeding hemorrhoids 2
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 2
- Office-based treatments, including rubber band ligation, are effective for grades I to III internal hemorrhoids and have a lower failure rate than infrared photocoagulation 2
- Excisional hemorrhoidectomy, either open or closed, can be used for recurrent or higher-grade disease, but may result in more pain and a prolonged recovery 2
Surgical Interventions
- Hemorrhoidectomy is a common surgical procedure for bleeding hemorrhoids that do not respond to other treatments 3
- Minimally invasive operations, such as Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy, have been introduced to reduce post-operative pain 4
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 2
Special Considerations
- Patients with special conditions, such as pregnancy, immunosuppression, or coagulopathy, require careful consideration and may benefit from conservative medical approaches 3
- In patients with portal hypertension and cirrhosis, a conservative treatment approach is recommended, with hemorrhoidectomy reserved for cases that do not respond to other treatments 3
- The use of electrocoagulation therapies, such as direct current and bipolar electrocoagulation, has been studied and shown to be effective in treating bleeding internal hemorrhoids 5