What is the recommended treatment method and technique for grade III bleeding hemorrhoids?

Treatment of Grade III Bleeding Hemorrhoids

Rubber band ligation is the recommended first-line procedural treatment for grade III bleeding hemorrhoids after conservative management, achieving success rates of 70.5–89% with approximately 90% of patients remaining asymptomatic at one year. 1

Initial Conservative Management (Mandatory First Step)

Before any procedural intervention, all patients with grade III hemorrhoids must receive conservative therapy:

• Increase dietary fiber to 25–30 grams daily (approximately 5–6 teaspoons of psyllium husk mixed with 600 mL water) to soften stool and reduce straining 1, 2
• Ensure adequate daily water intake to prevent constipation and minimize anorectal pressure during defecation 1
• Add flavonoid (phlebotonic) therapy to control acute bleeding through improvement of venous tone, though symptom recurrence reaches 80% within 3–6 months after cessation 1, 2, 3
• Avoid prolonged sitting on the toilet to prevent elevation of venous pressure in the hemorrhoidal plexus 1
• Perform warm-water sitz baths to reduce perianal inflammation and provide symptomatic relief 1

Topical Adjuncts for Symptom Relief

• Topical lidocaine 1.5–2% provides symptomatic relief of local pain and itching 1
• Topical corticosteroids may reduce local inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3

Procedural Treatment Algorithm

First-Line: Rubber Band Ligation

When conservative management fails after 1–2 weeks, rubber band ligation is the preferred office-based procedure for grade III internal hemorrhoids:

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and follow-up duration 1
• Approximately 90% of patients remain asymptomatic at 1-year follow-up, with 69% remaining asymptomatic at 10–17 years 1
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Can be performed in an office setting without anesthesia using commercially available suction devices 1

Critical Technical Requirements

• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 1
• Up to 3 hemorrhoidal columns can be banded in a single session, though many practitioners prefer to limit treatment to 1–2 columns at a time 1

Expected Complications

• Pain occurs in 5–60% of treated patients, typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Other complications include abscess, urinary retention, band slippage, and prolapse/thrombosis of adjacent hemorrhoids in approximately 5% of patients 1
• Severe bleeding may occur when the eschar sloughs, typically 1–2 weeks after treatment 1
• Repeated banding is needed in up to 20% of patients 4

Contraindications

Rubber band ligation is contraindicated in immunocompromised patients (including those with uncontrolled AIDS, neutropenia, and severe diabetes mellitus) due to increased risk of necrotizing pelvic infection 1

Alternative Office-Based Procedures (Less Effective)

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids but has no proven superiority over conservative management alone, with long-term remission occurring in only one-third of patients 1, 4
• Infrared photocoagulation has success rates of 67–96% for grade II hemorrhoids but requires more repeat treatments than rubber band ligation 1
• Bipolar diathermy has success rates for bleeding control of 88–100% in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated when:

• Rubber band ligation and other office-based procedures have failed 1
• Symptomatic grade III hemorrhoids persist despite conservative and procedural management 1
• Mixed internal and external hemorrhoids are present 1
• Active bleeding has caused anemia, as this represents a critical threshold demanding definitive surgical intervention 1
• Concomitant anorectal conditions (fissure, fistula) require surgery 1

Surgical Technique and Outcomes

• Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique) is the most effective treatment overall for grade III hemorrhoids, with a recurrence rate of only 2–10% 1, 4
• Ferguson (closed) technique may offer slightly improved wound healing and reduced postoperative pain compared to Milligan-Morgan (open) technique 1
• Most patients return to work within 2–4 weeks after conventional hemorrhoidectomy, with postoperative pain typically requiring narcotic analgesics 1
• Major complications include urinary retention (2–36%), bleeding (0.03–6%), anal stenosis (0–6%), infection (0.5–5.5%), and incontinence (2–12%) 1
• Sphincter defects occur in up to 12% of patients after hemorrhoidectomy, particularly when excessive tissue retraction or dilation is performed 1

Alternative Surgical Options

• Stapled hemorrhoidopexy shows less postoperative pain and faster return to normal activities but has a higher recurrence rate and lacks long-term follow-up data 1, 5
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence rates compared to conventional hemorrhoidectomy 6

Critical Diagnostic Requirements Before Treatment

Before attributing bleeding to hemorrhoids, the following evaluations are mandatory:

• Anoscopy should be performed when feasible to directly visualize hemorrhoids and exclude other anorectal pathology 1
• Colonoscopy is required for any patient with anemia, atypical bleeding patterns, or positive fecal occult blood testing to exclude proximal colonic pathology such as inflammatory bowel disease or colorectal cancer 1, 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
• Anemia due to hemorrhoidal disease is rare (approximately 0.5 patients per 100,000 population), and colonoscopy is necessary to exclude other causes 1
• Persistent anal pain is generally not associated with uncomplicated internal hemorrhoids and suggests other pathology such as anal fissure, abscess, or thrombosis 1

Common Pitfalls to Avoid

• Never delay definitive treatment when active bleeding has caused anemia, as the natural history will be continued blood loss 1, 2
• Do not use topical corticosteroids for more than 7 days due to risk of perianal tissue thinning and increased injury risk 1, 2, 3
• Avoid anal dilatation, which should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Do not use cryotherapy, which is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Never perform rubber band ligation on external hemorrhoids or below the dentate line, as this causes severe pain 1
• Do not rely on over-the-counter topical preparations as primary treatment for significant bleeding, as they lack evidence for effectiveness 2