Disease-specific history and physical examination for evaluation of hemorrhoids should emphasize degree and duration, according to new clinical practice guidelines from the American Society of Colon and Rectal Surgeons (ASCRS).
The guidelines are based on ASCRS practice parameters on this topic from 2011 and on a literature search through April 2017. Topics covered include evaluation of hemorrhoids and rectal bleeding, medical treatment of hemorrhoids, and procedure options, among others.
Evaluation of hemorrhoids should involve a disease-specific history and physical examination that emphasizes degree and duration of symptoms and risk factors, the guidelines recommend. Select patients with symptomatic hemorrhoids and rectal bleeding should receive complete endoscopic evaluation of the colon. “While the majority of patients with hematochezia will not have colorectal cancer, rectal bleeding attributed to hemorrhoids represents the most common missed opportunity to establish a cancer diagnosis,” the guidelines said.
Primary first-line therapy for patients with symptomatic hemorrhoid disease typically includes dietary modification to ensure adequate fluid and fiber intake and counseling on defecation habits, the guidelines recommend. “Constipation and abnormal bowel habits (eg, straining, prolonged sitting, and frequent bowel movements) can play a significant role in patients with symptomatic hemorrhoids,” the guidelines said. “Increased fiber and fluid intake should be recommended to all patients and have been shown to improve symptoms of mild-to-moderate prolapse and bleeding.”
The guidelines noted that a heterogenous group of treatment options are available for medical therapy and can be offered “with expectations of minimal harm and a decent potential for relief.” For most patients with grade I and II internal hemorrhoidal disease and select patients with grade III internal hemorrhoidal disease in whom medical therapy is not effective, office-based procedures such as banding, sclerotherapy, and infrared coagulation are recommended, with hemorrhoid banding typically the most effective, the guidelines said.
The guidelines also offer recommendations on treatment for thrombosed external hemorrhoids and surgical hemorrhoidectomy. They were published in the March Diseases of the Colon & Rectum and are available online.