Your hemorrhoid playbook: The AGA’s first expert review
The American Gastroenterology Association recently requested myself (lead author) and several colleagues to develop the first guideline for how to diagnose and treat hemorrhoids.
By the age of 50, nearly half of U.S. adults have symptomatic hemorrhoid disease. This may present as bleeding, itching, anal discomfort or prolapse. Hemorrhoids do not cause significant pain, unless a clot develops within a hemorrhoid, or it is associated with an anal tear caused by hard stool. Most treatments for hemorrhoid disease can be easily conducted by a practicing gastroenterologist in an outpatient setting with no need for anesthesia. The procedure is painless with no downtime. Sometimes hemorrhoid disease progresses to the point where the patient needs surgery.
To support prevention and management of this disease, our guideline emphasizes the following:
- Dietary and lifestyle modifications, including increasing fiber intake and avoiding straining or prolonged time on the toilet are reasonable first-line therapies for symptomatic hemorrhoids.
- In office procedures: Both hemorrhoid banding and infrared coagulation are safe, effective, and easy to perform in the office setting. Infrared coagulation and rubber band ligation have similar benefits in the short-term. Rubber band ligation has longer-term benefits for treatment of prolapsing hemorrhoids and recurrent bleeding. Hemorrhoid banding or infrared coagulation should be employed prior to surgical hemorrhoidectomy for grades 1-3 hemorrhoids.
- As part of informed consent for hemorrhoid therapies, the patient must be made aware of the small possibility of pelvic sepsis as a complication. Patients should be counseled about the risk and instructed to present to the emergency department immediately for evaluation, if indicated.
- In patients with active Crohn’s disease or ulcerative colitis, hemorrhoid disease management should be delayed until complete remission is achieved.
- Hemorrhoids occur in up to two thirds of women during pregnancy. Treatment should generally involve conservative management, including fiber, treatment of constipation and topical ointments. If symptoms persist postpartum, or if a woman is planning further pregnancies, standard treatment such as banding is considered.
- Acute thrombosed hemorrhoids are often painful. They are best treated surgically with incision and drainage.
- Consultation with a surgeon should be offered to patients with grade 3 internal hemorrhoids who fail banding procedures or have associated external hemorrhoids. Grade 4 internal hemorrhoids require surgical hemorrhoidectomy.
- Patients with liver cirrhosis and hemorrhoids should be carefully examined so as not to confuse hemorrhoids with rectal varices.
Final words of wisdom:
Eat plenty of fiber and stay well hydrated. Reduce consumption of red meat. Plant-based protein are preferred for many reasons that, including improvements in heart health and hemorrhoid prevention. Avoid spending more than five minutes sitting on the toilet. If you cannot have a bowel movement without your smart phone set an alarm for five minutes so that you know when to get up! If you think you have hemorrhoids, don’t just sit on them, see your doctor. The sooner they’re treated, the better the outcome. Office based treatments are quick and relatively painless. They are covered by most insurance policies.
By Dr. Waqar Qureshi, professor of medicine, Baylor College of Medicine
