The Management of Hemorrhoids

Section 1. Clinical diagnosis:

·  We recommend performing a disease-specific history and physical examination emphasizing the degree and duration of symptoms and risk factors, (Strong recommendation, low certainty evidence, ⁽²⁾).

Section 2. The indication for colonoscopy:

·  Complete endoscopic evaluation of the colon is recommended in select patients with symptomatic hemorrhoids and rectal bleeding, (conditional recommendation, low certainty evidence, ⁽²⁾).

Section 3. Medical therapy for hemorrhoids:

· Medical therapy for hemorrhoids is preferred as it carries minimal harm and has the potential for symptomatic relief, (conditional recommendation, low certainty evidence,

(2)).

· Dietary and behavioral modifications are recommended as the primary first-line therapies for patients with symptomatic hemorrhoidal disease, (strong recommendation, moderate certainty evidence, ⁽²⁾).

Section 4. Non-surgical treatment, (Office treatment):

·  Most patients with symptomatic grade I or II hemorrhoids and selected patients with grade III hemorrhoids refractory to conservative treatment can be effectively treated with office-based procedures. We recommend Haemorrhoid banding as an effective office-based treatment in these patients, (strong recommendation, moderate certainty evidence, ⁽²⁾).

· We recommend against injection sclerotherapy for treatment of hemorrhoids and recommend RBL instead of it, (strong recommendation, moderate certainty evidence, ⁽²⁾).

·  We recommend against infrared coagulation for treatment of hemorrhoids and recommend RBL instead of it, (strong recommendation, moderate certainty evidence, ⁽²⁾).

Section 5. Urgent manegement:

· We recommend early surgical evacuation of thrombosed external hemorrhoids, (conditional recommendation, low certainty evidence, ⁽²⁾).

Section 6. Operative, (surgical) treatment:

· Excisional hemorrhoidectomy is recommended for patients with external hemorrhoids or patients with symptomatic combined internal and external hemorrhoids (grades III–IV), (strong recommendation, high certainty evidence, ⁽²⁾).

· Doppler-guided hemorrhoid artery ligation may be recommended for patients with internal hemorrhoids, (conditional recommendation, moderate certainty evidence, ⁽²⁾).

· Stapled hemorrhoidopexy is not routinely recommended as a first-line surgical treatment for internal hemorrhoids given its marginal efficacy and significant risk, (conditional recommendation, moderate certainty evidence, ⁽²⁾).

Section 7. Laser haemorrhoidoplasty (LHP):

· Laser haemorrhoidoplasty (LHP), if available, is recommended for patients with first-, second-, and third-degree haemorrhoids, seeking a minimally invasive option with potentially reduced postoperative pain and quicker recovery, (Conditional Recommendation, moderate certainty evidence ⁽⁴⁾).

·  Laser haemorrhoidoplasty (LHP) is not recommended for grade 4 haemorrhoids and haemorrhoidal prolapse, (Strong recommendation, moderate certainty evidence ⁽⁴⁾).