Hemorrhoids are normal vascular and connective-tissue cushions of the anal canal that become symptomatic when engorged, prolapsed, or thrombosed. Clinically, the term refers to this symptomatic state rather than to the tissue itself. Symptoms may include painless, bright red bleeding with defecation (most common), mucus discharge and soiling, pruritus ani, sensation of incomplete evacuation, dull aching or discomfort, and in some instances anemia, although this is rare. Severe pain can occur with incarceration, strangulation, or thrombosis.
Most symptomatic hemorrhoids resolve with conservative management — high-fiber diet, adequate hydration, and sitz baths. For those that fail conservative treatment, office-based procedures or surgery may be beneficial.
In this Guidelines Side-by-Side comparison, we look at the latest clinical practice guidelines from the American Society of Colon and Rectal Surgeons (ASCRS) and the American Gastroenterological Association (AGA) on hemorrhoids.
| Item | The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids | AGA Clinical Practice Update on Diagnosis and Treatment of Hemorrhoids: Expert Review |
|---|---|---|
| Authoring Organization | American Society of Colon and Rectal Surgeons (ASCRS) | American Gastroenterological Association (AGA) |
| Publication Date | January 2024 | May 2026 |
| Graded Recommendations | Yes | No |
| Uses GRADE | Yes | No |
| Links | Summary / Full Text | Summary / Full Text |
Key Takeaways
Evaluation
- History and Physical Examination: Both guidelines agree with completing a disease-specific history and physical examination on patients with suspected hemorrhoids.
- Endoscopic Evaluation: The AGA recommends endoscopic evaluation for all new patients with suspected hemorrhoids before starting treatment to ensure accurate diagnosis, while the ASCRS recommends this evaluation just for certain patients with symptomatic hemorrhoids and rectal bleeding.
Treatment
- Non-Pharmacologic: Both the ASCRS and AGA recommend dietary and behavior modification as first-line therapies. The AGA makes note that while sitz bath is often recommended to improve symptoms scientific data is limited.
- Pharmacologic: The ASCRS broadly states that medical therapy may help relieve symptoms. The AGA is more specific, saying that topical treatments including anesthetics, astringents, corticosteroids (for a maximum of 2 weeks), and vasoactives may be considered for symptomatic hemorrhoids, but there is little efficacy data to support this.
- Office-Based Procedures: The ASCRS suggests that patients refractory to conservative treatment may be considered for office-based procedures based on hemorrhoid grade with banding being the most effective option. The AGA suggests both banding and infrared coagulation as safe and effective options for symptomatic hemorrhoids and should be used before surgical hemorrhoidectomy for grade 1 to 3 hemorrhoids. The AGA also adds a recommendation about informed consent, specifically that patients should be aware of the potential for pelvic sepsis as a complication. The ASCRS does not make a formal recommendation regarding informed consent but does note the very rare complication of perineal sepsis from hemorrhoid banding.
- Surgical: Both guidelines make suggestions for surgery of thrombosed external hemorrhoids. The ASCRS suggests early excision while the AGA recommends incision and drainage. Both guidelines recommend offering hemorrhoidectomy to certain patients. The ASCRS recommends this for symptomatic combined internal and external grade 3 to 4 hemorrhoids. The AGA recommends this for grade 4 hemorrhoids and suggests offering surgical consultation to patients with grade 3 hemorrhoids who fail banding or have associated external hemorrhoids. Both guidelines report doppler-guided hemorrhoid artery ligation may result in less pain compared to excisional hemorrhoidectomy. Both guidelines agree that stapled hemorrhoidopexy should not be routinely recommended because of higher complication rates and risk for recurrence.
- Special Patient Populations: The ASCRS did not address special patient populations. The AGA addressed hemorrhoid treatment for patients with Crohn’s disease or ulcerative colitis, women who are pregnant, and patients with cirrhosis.
- Crohn’s disease or ulcerative colitis: Delay hemorrhoid treatment until complete remission is achieved;
- Pregnant women: Treat with conservative management during pregnancy, after delivery may consider banding or infrared coagulation if symptoms persist or further pregnancies are planned;
- Cirrhosis: Determine if symptoms are due to hemorrhoids versus rectal varices. Hemorrhoids can be treated with banding or infrared coagulation (infrared coagulation is preferred in patients with significant coagulopathy).
| Type | ASCRS | AGA |
|---|---|---|
| Evaluation | A disease-specific history and physical examination should be performed, emphasizing the degree and duration of symptoms and risk factors. | The diagnosis and treatment of hemorrhoids is within the purview of the gastroenterologist. The diagnosis and grading of hemorrhoids is easily made by taking a history from the patient and examining the patient. Symptoms caused by hemorrhoids include bleeding, itching, discomfort, and/or prolapse. Hemorrhoids only cause significant pain when acutely thrombosed. Sharp pain on defecation is most likely anal fissure. |
| Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic hemorrhoids and rectal bleeding. | Anoscopy should be performed, whenever possible, on every new patient with suspected hemorrhoids, prior to treatment, to ensure accurate diagnosis. | |
| Treatment - Non-pharmacologic | Dietary and behavioral modifications are the primary first-line therapies for patients with symptomatic hemorrhoidal disease. | 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. The use of sitz baths for symptom improvement in symptomatic hemorrhoids is often advised, but scientific data is limited. |
| Treatment - Pharmacologic | Medical therapy for hemorrhoids, while heterogeneous, carries minimal harm and has the potential for symptomatic relief. | 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. |
| Treatment - In-Office Procedures | Most patients with symptomatic grade I or II hemorrhoids and select patients with grade III hemorrhoids refractory to conservative treatment can be effectively treated with office-based procedures. Hemorrhoid banding is considered the most effective office-based treatment. | 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 to 3 hemorrhoids. |
| No formal recommendation made but text states, "Perineal sepsis, a very rare but severe complication of RBL, is manifested by fever, severe anal pain, difficulty with micturition, fecal incontinence, and nausea/emesis. Broad-spectrum antibiotics and urgent examination under anesthesia are indicated in these patients." | 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. | |
| Treatment - Surgical | Select patients with thrombosed external hemorrhoids may benefit from early surgical excision. | Acute thrombosed hemorrhoids are often extremely painful. They are best treated surgically with incision and drainage. |
| Excisional hemorrhoidectomy should typically be offered to select patients with external hemorrhoids or patients with symptomatic combined internal and external hemorrhoids (grades III–IV). | 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. | |
| Doppler-guided hemorrhoid artery ligation may be used for patients with internal hemorrhoids. Compared with excisional hemorrhoidectomy, this approach may result in decreased pain but increased recurrence rates. | No formal recommendation but text states, "Doppler-guided hemorrhoidectomy utilizes a Doppler probe to identify and ligate the hemorrhoid artery without an excision. In some instances, the surgeon may choose to perform a mucosal pexy for symptomatic, prolapsed hemorrhoids. As no excision is performed, patients report less postoperative pain and it is well-tolerated with minimal complications." | |
| Stapled hemorrhoidopexy is not routinely recommended as a first-line surgical treatment for internal hemorrhoids given its marginal efficacy and significant risk profile. | No formal recommendation but text states that stapled hemorrhoidopexy, "was found to be well-tolerated, with patients experiencing less postoperative pain compared with excision hemorrhoidectomy. However, on long-term follow-up, patients were found to have an increased rate of recurrence. Due to the increased risk for significant complications, including rectovaginal fistula, rectal perforation, bleeding and staple-line stricture, hemorrhoidopexy has fallen out of favor as a surgical option for the treatment of internal hemorrhoids." | |
| Special Patient Populations | Not Addressed | In patients with active Crohn’s disease or ulcerative colitis, hemorrhoid disease management should be delayed until complete remission is achieved. |
| Not Addressed | 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 or infrared coagulation can be considered. | |
| Not Addressed | Patients with cirrhosis and hemorrhoids should be carefully examined so as not to confuse hemorrhoids with rectal varices. Hemorrhoids in patients with cirrhosis can be treated with banding or infrared coagulation. In patients with significant coagulopathy, infrared coagulation is preferred to banding. Concomitant portal hypertension should not alter this approach. For most clinicians, significant coagulopathy means a platelet count of less than 50,000 per microliter or international normalized ratio greater than 2.0. The presence of concomitant portal hypertension should not alter this approach. |
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