What is the most appropriate management for a 28-year-old woman with intermittent painless rectal bleeding, spontaneously reducing anal swelling, internal hemorrhoids at 3, 7, and 11 o’clock with active bleeding and anemia (hemoglobin 8.8 g/dL)?

Hemorrhoidectomy is the Most Appropriate Management

This 28-year-old woman with grade II-III internal hemorrhoids causing active bleeding and anemia (hemoglobin 8.8 g/dL) requires surgical hemorrhoidectomy as definitive treatment. 1, 2

Why Hemorrhoidectomy is Indicated

Active bleeding with anemia represents a critical threshold that mandates surgical intervention rather than conservative or office-based procedures. 1 The combination of:

• Multiple hemorrhoid columns at 3,7, and 11 o'clock positions
• Active bleeding visualized on anoscopy
• Clinically significant anemia (Hgb 8.8 g/dL)
• Spontaneously reducing prolapse (indicating grade II-III disease)

...collectively exceeds the threshold for non-operative management. 1, 2

Anemia from hemorrhoidal bleeding is rare (0.5 cases per 100,000 population annually) and indicates substantial chronic blood loss requiring definitive control. 1, 3 When anemia is present, the natural history without intervention is continued blood loss and worsening anemia. 1

Why Other Options Are Inadequate

Conservative Treatment (Option B) - Insufficient

Conservative management with fiber (25-30 g daily), increased fluids, and topical agents is appropriate only for first-degree hemorrhoids or mild symptoms without anemia. 1, 4 Once significant anemia has developed, dietary modifications and lifestyle changes cannot provide the definitive bleeding control required. 1

Flavonoid therapy, while temporarily reducing bleeding, shows 80% symptom recurrence within 3-6 months after discontinuation—unacceptable when anemia is already present. 1, 4

Rubber Band Ligation (Option C) - Suboptimal

While rubber band ligation achieves 70-89% success rates for grade II-III hemorrhoids, it is not recommended as first-line treatment when significant anemia is present. 1 The procedure works best for uncomplicated internal hemorrhoids without active bleeding complications. 1, 5

Multiple hemorrhoid columns suggest extensive disease that is less amenable to office procedures. 1 Active bleeding with anemia demands more definitive control than office-based ligation can reliably provide. 1

Follow-up Alone (Option A) - Dangerous

Observation without intervention leads to continued blood loss and progressive worsening of anemia. 1 Delaying definitive treatment when active bleeding has caused anemia allows the natural disease course to continue unchecked. 1, 2

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 (2-10%) for this degree of hemorrhoidal disease with complications. 1, 6

• Success rate approaches 90-98% for this indication 1
• Rapid hemoglobin recovery: mean 12.3 g/dL at 2 months, 14.1 g/dL at 6 months post-hemorrhoidectomy 3
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1

In the 2022 study of 53 patients with active hemorrhoidal bleeding and anemia (mean hemoglobin 7.5 g/dL), emergency hemorrhoidectomy was performed in 92.5% of cases with excellent outcomes. 6

Critical Pre-operative Requirements

Colonoscopy must be performed to exclude proximal colonic pathology before attributing anemia to hemorrhoids. 1, 4, 2 Hemorrhoids alone do not cause positive fecal occult blood tests, and anemia should never be assumed hemorrhoidal without proper colonic evaluation. 1, 4

Blood transfusion may be needed given the low hemoglobin level, and preoperative optimization should be considered if the patient is hemodynamically stable. 1

Common Pitfalls to Avoid

• Never delay definitive treatment when active bleeding has caused anemia—the natural history is continued blood loss 1, 2
• Never attribute anemia to hemorrhoids without colonoscopy to rule out inflammatory bowel disease, colorectal cancer, or other proximal pathology 1, 4, 2
• Do not attempt rubber band ligation as first-line therapy when significant anemia is already present 1
• Failure to recover hemoglobin concentration by 6 months post-hemorrhoidectomy should prompt repeated evaluation for other bleeding sources 3