AGA Clinical Practice Update on Diagnosis and Treatment of Hemorrhoids: Expert Review.
Published by American Gastroenterological Association Institute
Summary
AI-generatedHemorrhoids only cause significant pain when acutely thrombosed. Internal hemorrhoids are graded according to Goligher's classification based on the degree of prolapse, while external hemorrhoid description remains subjective.
Key Takeaways
- 1Expert review Best Practice Advice (BPA) statements do not carry formal grading for evidence quality or recommendation strength because systematic reviews were not performed.
- 2Topical treatments lack strong efficacy data and topical corticosteroids should be restricted to a maximum of 2 weeks of continuous use.
- 3Anoscopy is highly recommended for all new patients with suspected hemorrhoidal disease before starting any treatment.
- 4Patients must be explicitly warned about the risk of pelvic sepsis as a rare but serious complication of hemorrhoid therapies.
- 5Hemorrhoid treatments must be deferred in patients with active inflammatory bowel disease (Crohn's disease or ulcerative colitis) until complete disease remission is achieved.
- 6Anal fissures coexist with hemorrhoids in about 20% of cases and should always be treated prior to addressing the hemorrhoids.
- 7Grade 4 internal hemorrhoids necessitate surgical hemorrhoidectomy, while surgeon consultation is advised for refractory Grade 3 internal hemorrhoids.
Key Recommendations
Treatment
- BPA 3
Topical treatments, including anesthetics, astringents (witch hazel), corticosteroids, and vasoactive agents, can be considered for treatment of symptomatic hemorrhoids, but there is little data to support efficacy. Topical steroids should not be used for more than 2 weeks at a time.
Pharmacological Treatment
Diagnosis
- BPA 4
Anoscopy should be performed, whenever possible, on every new patient with suspected hemorrhoids prior to treatment to ensure accurate diagnosis.
Diagnostic Procedure
Complications and Counseling
- BPA 6
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.
Patient Counseling / Informed Consent
Special Populations
- BPA 7
In patients with active Crohn’s disease or ulcerative colitis, hemorrhoid disease management should be delayed until complete remission is achieved.
Clinical Management Strategy
Surgical Referral and Intervention
- BPA 10
Consultation with a surgeon should be offered to patients with grade 3 internal hemorrhoids who fail banding procedures or have associated external hemorrhoids. Large skin tags can be removed without a hemorrhoidectomy if they are not associated with significant hemorrhoids. Grade 4 internal hemorrhoids require surgical hemorrhoidectomy.
Surgical Referral / Intervention
Scope & Objectives
Clinical Topic
Hemorrhoids
Objectives
To provide timely guidance on a topic of high clinical importance to the AGA membership.
Target Patient Population
Patients with suspected or symptomatic hemorrhoids.
Diagnostic Criteria
Internal hemorrhoids are graded using Goligher's classification based on the degree of prolapse (primarily from patient history and confirmed on examination). Anoscopy is recommended prior to treatment.
Target Providers
Patient Criteria & Setting
Therapeutic Area
GastroenterologyGuideline Scope
Care Settings
Special Populations
Safety & Contraindications
Contraindications
- Active Crohn's disease (delay management until complete remission is achieved)
- Active ulcerative colitis (delay management until complete remission is achieved)
Authors & Contributors
Guideline Features
Learning Context
Difficulty
advanced
Learning Paths