How to manage rectal bleeding from hemorrhoids?

From the Guidelines

To manage rectal bleeding from hemorrhoids, non-operative management with dietary and lifestyle changes, such as increased fiber and water intake, should be the first-line therapy. This approach is supported by the most recent and highest quality study, which recommends non-operative management as the first-line therapy for patients with complicated hemorrhoids 1.

Key Recommendations

• Increase fiber intake to 25-30 grams daily to keep stools soft and reduce straining during bowel movements
• Drink plenty of water to maintain soft stools and prevent constipation
• Avoid straining during bowel movements
• Use stool softeners like docusate sodium (Colace) 100mg twice daily if constipation is an issue
• Apply direct pressure to the area with a clean, soft cloth or toilet paper for about 10-15 minutes to stop bleeding
• Take a warm sitz bath for 15-20 minutes, 2-3 times daily, to soothe the area and reduce bleeding

Medical Treatment

Over-the-counter treatments like witch hazel pads or creams containing hydrocortisone can help reduce bleeding and inflammation, but their effectiveness is not well-supported by evidence 1.

Procedure-Based Treatments

Rubber band ligation is a common procedure for treating hemorrhoids, with success rates varying depending on the degree of hemorrhoids treated and length of follow-up 1. However, this procedure is typically considered for patients who do not respond to non-operative management.

When to Seek Medical Attention

If bleeding is severe, persistent (lasting more than a week), or accompanied by severe pain, seek medical attention immediately. Recurrent or heavy bleeding may require medical procedures like rubber band ligation or surgical removal.

From the Research

Management of Rectal Bleeding from Hemorrhoids

• Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
• Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids, and can also be performed in patients with grade 3 hemorrhoids 2, 3, 4
• Excisional hemorrhoidectomy or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids, and is recommended for treatment of grade 4 hemorrhoids 2, 4
• Thrombosed external hemorrhoids can be treated conservatively or excised, with excision being the most effective treatment 2, 3, 4
• Non-operative approaches include sclerotherapy, rubber band ligation, and lifestyle modification, such as increased fiber and water intake, and behavioral therapies like sitz baths 5, 4, 6

Treatment Options

• Rubber band ligation: effective in 75% of patients in the short term, but does not treat prolapsed hemorrhoids or those with a significant external component 5
• Excisional hemorrhoidectomy: the most effective treatment in the long term, but has the main limitation of post-operative pain 5, 4
• Stapled hemorrhoidopexy: elevates grade III or IV hemorrhoids to their normal anatomic position, but has several potential postoperative complications 4
• Hemorrhoidal artery ligation: may be useful in grade II or III hemorrhoids, with less pain and quicker recovery 4

Considerations

• Correct evaluation is important to rule out more serious pathology 5
• Patient preference and comorbidities should be taken into account when determining the order of treatments 4
• Postoperative pain can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 2