A 28-year-old woman with intermittent painless rectal bleeding, transient anal swelling, anoscopic internal hemorrhoids at the 3, 7, and 11 o’clock positions with active bleeding and anemia (hemoglobin 8.8 g/dL); what is the most appropriate management?

Hemorrhoidectomy

This 28-year-old woman with grade 2–3 internal hemorrhoids causing active bleeding and anemia (hemoglobin 8.8 g/dL) requires surgical hemorrhoidectomy as the most appropriate management. 1

Rationale for Surgical Intervention

• Anemia from hemorrhoidal bleeding is a critical threshold that mandates definitive surgical treatment, as it indicates substantial chronic blood loss requiring immediate control rather than temporizing measures. 1

• The presence of active bleeding visualized on anoscopy combined with hemoglobin of 8.8 g/dL represents a complication that exceeds the threshold for conservative or office-based management. 1

• Without intervention, the natural history is continued blood loss and worsening anemia—observation or conservative therapy will not stop active hemorrhoidal bleeding of this magnitude. 1

• Multiple hemorrhoid columns at 3,7, and 11 o'clock positions suggest extensive disease that is less amenable to office procedures like rubber band ligation. 1

Why Other Options Are Inappropriate

Follow-up (Option A) is dangerous:

• Delaying definitive treatment when active bleeding has caused anemia allows continued blood loss and potential hemodynamic compromise. 1
• The patient has already developed anemia, proving that the hemorrhoids are causing clinically significant bleeding that will not resolve spontaneously. 1

Conservative treatment (Option B) is insufficient:

• Dietary fiber (25–30 g daily), increased fluids, flavonoids, and topical agents constitute first-line therapy only for uncomplicated hemorrhoids without anemia. 1
• These measures are inadequate when significant anemia is already present, as they do not provide definitive hemostasis. 1
• Even flavonoids, which can temporarily reduce bleeding, have 80% symptom recurrence within 3–6 months after discontinuation. 1

Rubber band ligation (Option C) has limitations here:

• While rubber band ligation achieves 70.5–89% success rates for grade 2–3 hemorrhoids, it is not recommended as first-line treatment when significant anemia is present. 1
• The American Gastroenterological Association reserves office-based procedures for hemorrhoids without complications like anemia. 1
• Multiple bleeding columns and active hemorrhage make complete hemostasis with banding less reliable. 1

Surgical Approach and Expected Outcomes

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) provides the most definitive treatment with the lowest recurrence rate of 2–10%. 1

• Success rates approach 90–98% for this indication (symptomatic grade 2–3 hemorrhoids with bleeding complications). 1

• The Ferguson closed technique may offer slightly improved wound healing compared to the open technique, with comparable efficacy. 1

Critical Pre-operative Requirements

• Colonoscopy must be performed to exclude proximal colonic pathology (inflammatory bowel disease, colorectal cancer, diverticular disease) before attributing anemia to hemorrhoids. 1, 2

• Never attribute anemia to hemorrhoids without complete colonic evaluation, especially in patients with atypical bleeding or risk factors for malignancy. 1, 2

• Anemia from hemorrhoidal disease is actually rare (0.5 per 100,000 population), so other sources must be ruled out. 2

• Check complete blood count, coagulation studies, and obtain blood type and crossmatch given the low hemoglobin. 1

• Blood transfusion may be needed given hemoglobin of 8.8 g/dL, and preoperative optimization should be considered if the patient is hemodynamically stable. 1

Post-operative Expectations

• Narcotic analgesics are generally required for postoperative pain management after surgical hemorrhoidectomy. 1

• Most patients do not return to work for 2–4 weeks following surgery. 1

• Emphasize high-fiber diet and adequate hydration postoperatively to prevent constipation and straining, which could compromise surgical healing. 1

Common Pitfalls to Avoid

• Do not perform simple incision and drainage if external thrombosis is also present—this leads to persistent bleeding and higher recurrence. 1

• Avoid anal dilatation as an adjunct procedure—it causes sphincter injuries and 52% incontinence rate at long-term follow-up. 1

• Do not use cryotherapy—it causes prolonged pain, foul-smelling discharge, and requires more additional therapy. 1

• Never skip colonoscopy in a patient with anemia and rectal bleeding, even when hemorrhoids are clearly visible on anoscopy. 1, 2