AGA Clinical Practice Update on Diagnosis and Treatment of Hemorrhoids: Expert Review.

Published by American Gastroenterological Association Institute

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Summary

AI-generated

Hemorrhoids 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.

HemorrhoidsInternal HemorrhoidsExternal HemorrhoidsAnoscopyTopical CorticosteroidsHemorrhoidectomyPelvic SepsisInflammatory Bowel Disease

Key Takeaways

1
Expert review Best Practice Advice (BPA) statements do not carry formal grading for evidence quality or recommendation strength because systematic reviews were not performed.
2
Topical treatments lack strong efficacy data and topical corticosteroids should be restricted to a maximum of 2 weeks of continuous use.
3
Anoscopy is highly recommended for all new patients with suspected hemorrhoidal disease before starting any treatment.
4
Patients must be explicitly warned about the risk of pelvic sepsis as a rare but serious complication of hemorrhoid therapies.
5
Hemorrhoid treatments must be deferred in patients with active inflammatory bowel disease (Crohn's disease or ulcerative colitis) until complete disease remission is achieved.
6
Anal fissures coexist with hemorrhoids in about 20% of cases and should always be treated prior to addressing the hemorrhoids.
7
Grade 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

Gastroenterologists

Patient Criteria & Setting

Therapeutic Area

Gastroenterology

Guideline Scope

DiagnosisTreatment

Care Settings

OutpatientEmergency Department

Special Populations

Crohn's diseaseulcerative colitis

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

Waqar Qureshi

Guideline Features

Dosing information

Learning Context

Difficulty

advanced

Learning Paths

GastroenterologyAnorectal DisordersSurgical ReferralsInternal and External HemorrhoidsClinical Practice Update