From the Guidelines
Emergency department admission for hemorrhoids is generally not indicated unless there are severe complications, such as thrombosed hemorrhoids causing severe pain, significant rectal bleeding, severe infection, or strangulated hemorrhoids. Most hemorrhoids can be managed on an outpatient basis with conservative measures, as suggested by the American Gastroenterological Association 1. However, emergency evaluation is warranted for severe cases, including thrombosed hemorrhoids causing severe pain unresponsive to over-the-counter medications, significant rectal bleeding leading to anemia or hemodynamic instability, severe infection or abscess formation, or strangulated hemorrhoids causing tissue necrosis.
In these cases, patients may require urgent surgical intervention, such as hemorrhoidectomy, rubber band ligation, or thrombectomy, as indicated by recent guidelines 1. For severe bleeding, blood transfusions might be necessary, and patients with sepsis from infected hemorrhoids need IV antibiotics and possibly surgical drainage. The urgency stems from the risk of significant blood loss, tissue death, or systemic infection if these complications are left untreated.
Some key points to consider in the management of hemorrhoids in the emergency department include:
- Thrombosed hemorrhoids: surgical excision may be beneficial in selected patients, with the decision based on physician expertise and patient preference 1.
- Bleeding hemorrhoids: no clear recommendation can be made regarding the role of surgery, but patients should be evaluated for severity of bleeding and risk stratified accordingly 1.
- Severe infection or abscess formation: IV antibiotics and possibly surgical drainage may be necessary.
- Strangulated hemorrhoids: urgent surgical intervention may be required to prevent tissue necrosis.
Most uncomplicated hemorrhoids can be managed with increased fiber intake, topical treatments, sitz baths, and pain management, reserving emergency care for truly severe presentations that cannot be safely managed in an outpatient setting, as supported by recent studies 1.
From the Research
Emergency Department Admission Indication for Hemorrhoid
- Hemorrhoidal disease is a common pathology that can cause significant patient distress, with symptoms such as bleeding, prolapse, or thrombosis 2.
- Acute presentation related to significant thrombosis or bleeding is referred to as acute hemorrhoidal crisis, which may require emergency department admission 2.
- The management of hemorrhoidal disease varies from nonoperative intervention for symptom control to definitive incisional or excisional hemorrhoidectomy 2, 3, 4.
Indications for Emergency Department Admission
- Severe bleeding or thrombosis that requires immediate attention 2, 5.
- Hemodynamic instability due to bleeding 5.
- Significant pain or discomfort that cannot be managed with oral medications 3.
- Presence of comorbidities that may complicate the management of hemorrhoidal disease 3, 5.
Evaluation and Treatment in the Emergency Department
- Evaluation of the patient's symptoms, medical history, and physical examination to determine the severity of the hemorrhoidal disease 3, 6.
- Aggressive resuscitation to achieve hemodynamic stabilization 5.
- Repletion of volume and blood loss, and reversal of coagulopathy if necessary 5.
- Identification of the source of bleeding and appropriate interventions to control it 5.