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hemorrhoids AND treatment

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2024 ASCRS clinical practice guideline hemorrhoids fiber office treatment hemorrhoidectomy

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Case diagnosis

This patient has symptomatic mixed hemorrhoids, with a grade III internal hemorrhoidal component:

Internal hemorrhoids are above the dentate line, covered by relatively insensitive mucosa, and commonly cause painless bright-red bleeding with defecation and prolapse.
External hemorrhoids are below the dentate line, covered by sensitive anoderm. The photo shows an external component with skin-covered tissue and an internal mucosal component, hence “mixed hemorrhoids.”
Grade III internal hemorrhoids prolapse and require manual reduction. Grade IV are irreducible.

The important caveat is that a 67-year-old with rectal bleeding must not automatically be assumed to have bleeding only from hemorrhoids. He needs colorectal evaluation before definitive hemorrhoid treatment.

References: Schwartz's Principles of Surgery, 11th ed., “Hemorrhoids”; Sabiston Textbook of Surgery, “Hemorrhoidal Disease”; Fischer’s Mastery of Surgery, 8th ed., “Hemorrhoids.”

1. Differential diagnosis of a perianal mass

Condition	Typical distinguishing features
Hemorrhoids	Bright-red bleeding, prolapse with straining; internal hemorrhoids are usually painless; thrombosed external hemorrhoids are acutely painful, bluish, and tender.
Anal skin tag	Soft, painless redundant perianal skin, often residual after a thrombosed external hemorrhoid or fissure.
Anal fissure with sentinel tag	Severe cutting pain during/after defecation, often with a small amount of blood; chronic fissure may have a sentinel pile.
Perianal abscess	Constant throbbing pain, tender fluctuant swelling, fever or systemic illness.
Fistula-in-ano	Recurrent perianal discharge, external opening, prior abscess.
Rectal prolapse	Circumferential protrusion with concentric folds, unlike the discrete cushions of hemorrhoidal prolapse.
Anal/rectal polyp or prolapsing rectal lesion	Mass and bleeding; requires proctoscopy and often colonoscopy.
Anal carcinoma	Indurated, ulcerated, irregular or fixed lesion; pain, bleeding, altered bowel habit, weight loss, inguinal nodes may occur. Biopsy is required.
Condyloma acuminata	Multiple verrucous, cauliflower-like lesions.
Hidradenitis/pilonidal disease	Recurrent painful nodules, sinuses, or discharge in characteristic skin-bearing areas.

A painful lump suggests thrombosis, abscess, fissure, or malignancy more than uncomplicated internal hemorrhoids. A painless bleeding/prolapsing mass favors internal hemorrhoids, but malignancy must be excluded in older patients.

References: S. Das, A Manual on Clinical Surgery, 13th ed., “Anal Conditions with Pain”; Sabiston Textbook of Surgery, “Common Benign Disorders of the Anus”; Fischer’s Mastery of Surgery, 8th ed., “Diagnosis.”

2. Benign versus malignant anal pathology: key history

Features favoring benign hemorrhoidal disease

Bright-red blood on paper, coating stool, or dripping into the bowl
Bleeding associated with defecation or straining
Intermittent protrusion that reduces spontaneously or manually
Itching, mucus discharge, soiling, or hygiene difficulty
Constipation, hard stools, prolonged toilet sitting, low-fiber diet
No constitutional symptoms

Red flags for malignancy or other colorectal pathology

New bleeding in an older adult, especially age over 50
Change in bowel habit, caliber of stool, tenesmus, persistent diarrhea or constipation
Unexplained iron-deficiency anemia
Weight loss, anorexia, fatigue
Persistent anorectal pain or a nonhealing ulcer
Palpable hard, irregular, fixed mass
Family history of colorectal cancer/polyposis
Personal history of inflammatory bowel disease, colorectal polyps, or pelvic irradiation

This patient has no weight loss or altered bowel habit, but his age (67 years) and recurrent bleeding justify colonoscopic assessment, especially as his last colonoscopy was 7 years ago.

Reference: Sabiston Textbook of Surgery, “Internal Hemorrhoids,” recommends history focused on bleeding, prolapse, bowel habits, stool caliber, evacuation difficulty, continence, inspection, digital rectal examination, and anoscopy.

3. Types of hemorrhoids

Anatomical types

Internal hemorrhoids
- Proximal to the dentate line
- Covered by columnar/anorectal mucosa
- Usually painless
- Present with bleeding and prolapse
External hemorrhoids
- Distal to the dentate line
- Covered by anoderm/squamous epithelium
- Painful when thrombosed because the anoderm is richly innervated
Mixed hemorrhoids
- Have both internal and external components
- This is the pattern shown in the case image.

Goligher grading of internal hemorrhoids

Grade	Description
I	Bleed but do not prolapse
II	Prolapse with defecation/straining but reduce spontaneously
III	Prolapse and require manual reduction
IV	Permanently prolapsed and irreducible, with risk of strangulation

References: Schwartz's Principles of Surgery, 11th ed., “Hemorrhoids”; Sabiston Textbook of Surgery, “Internal Hemorrhoids.”

4. Role of fiber in hemorrhoidal disease

Fiber is first-line treatment because it:

Produces softer, bulkier stools
Reduces constipation and straining
Reduces time spent on the toilet
Reduces bleeding and prolapse-related symptoms
Helps prevent recurrence after office or operative treatment

Counseling

Aim for 20 to 35 g dietary fiber/day.
Ensure adequate fluid intake, approximately 64 oz/day or more, unless medically contraindicated.
Use dietary sources: vegetables, fruits, legumes, whole grains.
A bulk-forming supplement such as psyllium may be added and increased gradually to reduce bloating.
Avoid straining and limit toilet time to about 2 to 3 minutes. Avoid reading or using a phone while on the toilet.
Stool softeners may be used if constipation persists.

Sabiston states that conservative management should optimize bowel and toilet habits, with fiber and hydration to maintain soft, formed, easy-to-pass stool. Schwartz recommends fiber, stool softeners, fluids, and avoidance of straining for bleeding grade I-II hemorrhoids.

References: Sabiston Textbook of Surgery, “Internal Hemorrhoids”; Schwartz's Principles of Surgery, 11th ed., “Medical Therapy.” The 2024 ASCRS guideline also recommends fiber and fluids as first-line management; it reports lower persistent symptoms with fiber.

5. Endoscopic options: anoscopy, proctoscopy, flexible sigmoidoscopy, colonoscopy

Test	What it assesses	Typical role
Anoscopy	Anal canal and distal rectum	Best office test to identify internal hemorrhoids, fissures, distal proctitis, anal lesions; can assess hemorrhoid grade and facilitate banding.
Proctoscopy/rigid sigmoidoscopy	Anal canal, rectum, and lower sigmoid	Identifies rectal polyps, tumors, proctitis, and distal bleeding sources.
Flexible sigmoidoscopy	Rectum and left colon	Useful for distal colonic disease, but does not examine the whole colon.
Colonoscopy	Entire colon and terminal ileum when reached	Required to exclude colorectal cancer, polyps, colitis, angiodysplasia, or another proximal source of bleeding. Also permits biopsy and polypectomy.

Best option in this patient

He should undergo colonoscopy, not merely anoscopy or flexible sigmoidoscopy, because he is 67 with recurrent rectal bleeding and is due for age-appropriate colorectal reassessment. Anoscopy has already demonstrated grade III hemorrhoids, but hemorrhoids do not exclude a second colonic lesion.

References: Fischer’s Mastery of Surgery, 8th ed., “Diagnosis”; Mulholland and Greenfield’s Surgery, 7th ed., “Evaluation.”

6. Surgical and procedural options

A. Conservative treatment first

Appropriate initially if symptoms are mild:

High-fiber diet/fiber supplement, fluids
Treat constipation and avoid straining
Sitz baths for symptom relief
Good perianal hygiene
Short-term topical agents may relieve symptoms, though evidence is limited

However, grade III prolapse often needs an office procedure or surgery if symptoms persist.

B. Office-based procedures

Rubber-band ligation, RBL
- Preferred office treatment for grade I, II, and selected grade III internal hemorrhoids.
- Band is placed 1 to 2 cm above the dentate line to avoid severe pain.
- Produces ischemic necrosis, scarring, and fixation of mucosa, reducing bleeding and prolapse.
- Often done in stages, one or two columns per visit.
- Risks: pain if placed too low, delayed bleeding around 7-10 days, urinary retention, infection, rare pelvic sepsis.
Infrared coagulation
- Coagulates and scars tissue above the dentate line.
- Best for smaller grade I-II bleeding hemorrhoids.
- Less effective for significant grade III prolapse.
Injection sclerotherapy
- Useful mainly for bleeding internal hemorrhoids, especially if banding is unsuitable.
- Less effective for large prolapse.

C. Operative treatment

Excisional hemorrhoidectomy
- Open Milligan-Morgan or closed Ferguson technique.
- Best definitive procedure for:
  - Symptomatic grade III-IV hemorrhoids
  - Significant external or mixed hemorrhoids
  - Failure of office therapy
  - Large prolapse or recurrent disease
- In this patient, it is a strong option if he has troublesome mixed disease or persistence after RBL.
- Risks include postoperative pain, bleeding, urinary retention, anal stenosis, skin tags, and rarely continence disturbance or pelvic sepsis.
Doppler-guided hemorrhoidal artery ligation with mucopexy
- May cause less postoperative pain than excisional hemorrhoidectomy.
- Can be considered for internal hemorrhoids, but recurrence may be higher.
Stapled hemorrhoidopexy
- Lifts prolapsing internal mucosa.
- Does not remove the external component, so it is less suitable for substantial mixed hemorrhoids.
- Has recurrence and potentially serious complication concerns; it is not routinely preferred as first-line surgery.

Practical plan for this patient

Colonoscopy to exclude another cause of bleeding.
Continue fiber, fluids, stool-softening strategy, and toilet-habit counseling.
If bleeding/prolapse persists: rubber-band ligation is reasonable for the grade III internal component.
If the mixed external component is significantly symptomatic, or if RBL fails: offer excisional hemorrhoidectomy after discussing pain, recovery, recurrence, and complications.

References: Schwartz's Principles of Surgery, 11th ed., “Hemorrhoids” and “Rubber Band Ligation”; Sabiston Textbook of Surgery, “Hemorrhoidal Disease”; Fischer’s Mastery of Surgery, 8th ed., “Rubber-Band Ligation” and “Hemorrhoidectomy.”

Shortly

Case: Mixed hemorrhoids with Grade III internal hemorrhoids

Differential diagnosis of perianal mass
- Hemorrhoids
- Thrombosed external hemorrhoid
- Anal fissure with sentinel tag
- Perianal abscess/fistula
- Rectal prolapse
- Anal polyp or carcinoma
- Condyloma
Benign vs malignant history
- Hemorrhoids: painless bright-red bleeding during defecation, prolapse, constipation/straining.
- Malignancy red flags: weight loss, anemia, change in bowel habit, tenesmus, hard/fixed ulcerated mass, persistent pain.
Types of hemorrhoids
- Internal: above dentate line, painless bleeding.
- External: below dentate line, painful if thrombosed.
- Mixed: both components.
- Grade III: prolapse requiring manual reduction.
Fiber advice
- Fiber 20-35 g/day, adequate fluids, stool softeners if needed.
- Avoid straining and prolonged toilet sitting.
- Reduces bleeding, constipation, and recurrence.
Endoscopy
- Anoscopy: anal canal/internal hemorrhoids.
- Proctoscopy: rectum/distal sigmoid.
- Flexible sigmoidoscopy: left colon.
- Colonoscopy: full colon; indicated here because he is 67 with rectal bleeding.
Treatment
- First: fiber, fluids, bowel-habit modification, sitz baths.
- Grade III: rubber-band ligation is suitable for selected cases.
- Persistent symptomatic mixed Grade III disease: excisional hemorrhoidectomy is definitive.
- Stapled hemorrhoidopexy/HAL may be considered for selected internal hemorrhoids but are less suitable for a major external component.

References:

Schwartz’s Principles of Surgery, 11th ed., Hemorrhoids.
Sabiston Textbook of Surgery, Hemorrhoidal Disease.
Fischer’s Mastery of Surgery, 8th ed., Hemorrhoids.

## Case: Mixed hemorrhoids with Grade III internal hemorrhoids 1. **Differential diagnosis of perianal mass** - Hemorrhoids - Thrombosed external hemorrhoid - Anal fissure with sentinel tag - Perianal abscess/fistula - Rectal prolapse - Anal polyp or carcinoma - Condyloma 2. **Benign vs malignant history** - **Hemorrhoids:** painless bright-red bleeding during defecation, prolapse, constipation/straining. - **Malignancy red flags:** weight loss, anemia, change in bowel habit, tenesmus, hard/fixed ulcerated mass, persistent pain. 3. **Types of hemorrhoids** - Internal: above dentate line, painless bleeding. - External: below dentate line, painful if thrombosed. - Mixed: both components. - Grade III: prolapse requiring manual reduction. 4. **Fiber advice** - Fiber 20-35 g/day, adequate fluids, stool softeners if needed. - Avoid straining and prolonged toilet sitting. - Reduces bleeding, constipation, and recurrence. 5. **Endoscopy** - **Anoscopy:** anal canal/internal hemorrhoids. - **Proctoscopy:** rectum/distal sigmoid. - **Flexible sigmoidoscopy:** left colon. - **Colonoscopy:** full colon; indicated here because he is 67 with rectal bleeding. 6. **Treatment** - First: fiber, fluids, bowel-habit modification, sitz baths. - Grade III: rubber-band ligation is suitable for selected cases. - Persistent symptomatic mixed Grade III disease: **excisional hemorrhoidectomy** is definitive. - Stapled hemorrhoidopexy/HAL may be considered for selected internal hemorrhoids but are less suitable for a major external component. **References:** - *Schwartz’s Principles of Surgery*, 11th ed., Hemorrhoids. - *Sabiston Textbook of Surgery*, Hemorrhoidal Disease. - *Fischer’s Mastery of Surgery*, 8th ed., Hemorrhoids. \humanize

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Case Summary: Mixed Hemorrhoids with Grade III Internal Hemorrhoids

This patient most likely has mixed hemorrhoids, meaning both internal and external components are present. The internal hemorrhoids are Grade III because they prolapse during defecation and need to be pushed back manually.

1. Differential diagnosis of a perianal mass

Other conditions that can present as a perianal lump include:

Thrombosed external hemorrhoid
Anal fissure with a sentinel skin tag
Perianal abscess or fistula-in-ano
Rectal prolapse
Anal polyp
Anal or rectal carcinoma
Condyloma acuminata

2. Features suggesting benign or malignant disease

Hemorrhoids typically cause painless, bright-red bleeding during or after passing stool, often with prolapse. Constipation, straining, and prolonged sitting on the toilet are common contributing factors.

Features that raise concern for malignancy include weight loss, anemia, altered bowel habits, narrow stools, tenesmus, persistent pain, and a hard, irregular, fixed, or ulcerated mass.

3. Types of hemorrhoids

Internal hemorrhoids: Located above the dentate line. They usually cause painless bleeding and prolapse.
External hemorrhoids: Located below the dentate line. They can be painful, especially when thrombosed.
Mixed hemorrhoids: Have both internal and external components.
Grade III internal hemorrhoids: Prolapse during defecation and require manual reduction.

4. Advice regarding fiber

The patient should increase dietary fiber to about 20-35 g/day and drink adequate fluids. Fiber helps produce soft stools, reduces constipation and straining, and may reduce hemorrhoidal bleeding and recurrence. Stool softeners can be added if required. He should avoid prolonged sitting and straining during defecation.

5. Endoscopic evaluation

Anoscopy: Examines the anal canal and helps identify internal hemorrhoids.
Proctoscopy: Examines the rectum and distal sigmoid colon.
Flexible sigmoidoscopy: Examines the rectum and left side of the colon.
Colonoscopy: Examines the entire colon and is appropriate in this 67-year-old patient with rectal bleeding to rule out polyps, colorectal cancer, or other causes of bleeding.

6. Management

Initial treatment includes a high-fiber diet, adequate fluids, correction of constipation, avoidance of straining, and warm sitz baths.

If symptoms continue, rubber-band ligation is an effective office procedure for selected Grade III internal hemorrhoids. If there is persistent troublesome prolapse, recurrent bleeding, or a large symptomatic external component, excisional hemorrhoidectomy is the definitive surgical treatment.

References: Schwartz’s Principles of Surgery, 11th ed., “Hemorrhoids”; Sabiston Textbook of Surgery, “Hemorrhoidal Disease”; Fischer’s Mastery of Surgery, 8th ed., “Hemorrhoids.”

Explain the picture in the qur

Explain the picture in the question

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hemorrhoids AND classification

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ASCRS hemorrhoids internal external mixed dentate line grade III 2024

The picture shows mixed hemorrhoids.

The red, moist tissue is the internal hemorrhoidal component. It is covered by rectal/anal mucosa and has prolapsed outside the anus.
The skin-covered tissue at the anal margin is the external hemorrhoidal component.
Therefore, the lesion has both internal and external parts, so it is called a mixed hemorrhoid.
The arrows in the original figure identify these two components:
- Blue arrow: internal, mucosa-covered hemorrhoid
- Tan arrow: external, squamous epithelium/skin-covered component

The internal component is prolapsing. In the case, anoscopy identifies Grade III internal hemorrhoids, meaning they prolapse and require manual reduction.

Unlike a thrombosed external hemorrhoid, this lesion is usually not very painful or tender, unless thrombosis, strangulation, or necrosis occurs.

Reference: Mulholland and Greenfield’s Surgery, 7th ed., “Hemorrhoids”; Schwartz’s Principles of Surgery, 11th ed., “Hemorrhoids.”

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