What is the treatment for bleeding hemorrhoids?

Treatment of Bleeding Hemorrhoids

First-line treatment for bleeding hemorrhoids should include conservative measures such as increased fiber and water intake, proper bathroom habits to avoid straining, and topical treatments for symptom relief. 1, 2

Initial Assessment and Classification

• A complete physical examination including digital rectal examination should be performed to rule out other causes of lower gastrointestinal bleeding 2
• Anoscopy should be performed when feasible to assess for internal hemorrhoids 1, 2
• Hemorrhoids are classified as internal (originating above the dentate line) or external (arising below the dentate line) 1
• Internal hemorrhoids are further graded from I to IV based on the degree of prolapse 1

Conservative Management (First-Line)

• Increased dietary fiber and water intake to soften stool and reduce straining is essential for all hemorrhoid grades 1, 2
• Recommended fiber supplementation: 5-6 teaspoonfuls of psyllium husk with 600 mL water daily 1, 3
• Proper bathroom habits to avoid prolonged straining during defecation 1, 3
• Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Management

• Topical treatments provide symptomatic relief for bleeding hemorrhoids 1, 4:
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) 5, 2
  • Topical analgesics like lidocaine provide relief from local pain and itching 1, 4
  • Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 5, 1, 2
• Flavonoids can be used to improve venous tone and control acute bleeding 4

Office-Based Procedures (Second-Line)

• For persistent bleeding despite conservative measures, office-based procedures should be considered 1:
  • Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, with success rates up to 89% 1, 2
  • The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Sclerotherapy is suitable for first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Infrared coagulation can be used for first and second-degree hemorrhoids with 70-80% success in reducing bleeding 6

Surgical Management (Third-Line)

• Surgical intervention is indicated when conservative and office-based approaches have failed or complications have occurred 5, 1:
  • Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10% 1, 2, 6
  • For thrombosed hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia is preferred for faster symptom resolution 1, 2
  • Simple incision and drainage of thrombosed hemorrhoids is NOT recommended due to persistent bleeding and higher recurrence rates 5, 1

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours), excision under local anesthesia is recommended 1
• For later presentation (>72 hours), conservative management is preferred, including stool softeners and analgesics 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks shows a 92% resolution rate compared to 45.8% with lidocaine alone 5

Important Considerations and Pitfalls

• Steroid creams should be applied for no more than 7 days to avoid thinning of perianal and anal mucosa 5, 1
• Colonoscopy should be considered if there is concern for inflammatory bowel disease or cancer 2
• Hemorrhoids alone do not cause positive stool guaiac tests, so fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Anal dilatation is not recommended due to high rates of associated incontinence 1