What is the treatment for an actively bleeding hemorrhoid?

Treatment for Actively Bleeding Hemorrhoids

The first-line treatment for actively bleeding hemorrhoids includes increasing dietary fiber and water intake, topical treatments for symptom relief, and rubber band ligation for persistent bleeding in grades 1-3 internal hemorrhoids. 1

Initial Assessment and Classification

• Proper diagnosis is essential as symptoms from other conditions are frequently misattributed to hemorrhoids; a careful anorectal evaluation is warranted for any patient reporting hemorrhoid symptoms 2
• Internal hemorrhoids are classified into four grades: first-degree (bleeding without prolapse), second-degree (prolapse with spontaneous reduction), third-degree (prolapse requiring manual reduction), and fourth-degree (irreducible prolapse) 1, 3
• External hemorrhoids typically become symptomatic only when thrombosed, presenting with acute pain and a palpable perianal lump 2

Conservative Management for Bleeding Hemorrhoids

• Conservative management is the first-line approach for all hemorrhoid grades, focusing on dietary and lifestyle modifications 1, 3
• Key components include:
  • Increased fiber (25-30g daily) and water intake to soften stool and reduce straining 1, 4
  • Avoiding prolonged toilet sitting and straining during defecation 1
  • Warm sitz baths for 10-15 minutes several times daily to reduce swelling and discomfort 4
  • Topical analgesics containing lidocaine for pain and itching relief 1, 5
  • Short-term use of topical corticosteroids (≤7 days) to reduce local inflammation 1, 5

Pharmacological Management

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks has shown a 92% resolution rate for symptomatic hemorrhoids 1, 5
• Flavonoids (phlebotonics) can reduce bleeding, rectal pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after treatment cessation 3, 6
• Avoid long-term use of high-potency corticosteroid suppositories as they can potentially harm anal tissue through thinning 1, 5

Office-Based Procedures for Persistent Bleeding

• Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids that continue to bleed despite conservative management 1, 4

  • Success rates range from 70.5% to 89% depending on hemorrhoid grade 1
  • The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer to limit treatment to 1-2 columns at a time 1

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids 1

  • Efficacious in the short term (weeks to months) among 70% to 85% of patients 3
  • Long-term remission occurs in only one-third of patients 3

Surgical Management for Severe or Refractory Cases

• Hemorrhoidectomy is indicated for:

  • Failure of medical and non-operative therapy 1
  • Symptomatic third or fourth-degree hemorrhoids 1, 4
  • Mixed internal and external hemorrhoids 1
  • Severe or persistent bleeding not controlled by other methods 7

• Conventional excisional hemorrhoidectomy is the most effective treatment overall, with a low recurrence rate of 2-10%, though it requires longer recovery (9-14 days) 1, 3

Management of Thrombosed External Hemorrhoids That Have Ruptured

• For a thrombosed hemorrhoid that has burst:
  • Clean the area gently with warm water and mild soap 5
  • Apply direct pressure if active bleeding is present 5
  • Surgical excision is generally not necessary as natural drainage has occurred 5
  • Continue conservative measures including sitz baths and topical treatments 5

Important Considerations and Follow-up

• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 5
• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 2
• Complete colonic evaluation by colonoscopy or air-contrast barium enema is indicated when bleeding is atypical for hemorrhoids, when no source is evident on anorectal examination, or when the patient has significant risk factors for colonic neoplasia 2