Hemorrhoids

Hemorrhoids are normal vascular cushions that can cause symptoms when they enlarge, bleed, or prolapse. They are also called piles. Many symptoms improve with bowel-habit changes, while persistent bleeding, prolapse, or pain may need an office procedure or surgery.

Symptomatic hemorrhoidal disease includes internal and external presentations with different patterns of bleeding, prolapse, swelling, and pain. Rectal bleeding must not automatically be attributed to hemorrhoids: appropriate assessment considers the history, examination, age, risk factors, and whether evaluation of the colon is indicated. [1]

Pattern comparison

Differential diagnosis

Anal fissure

Tearing pain with bowel movements is more typical than painless internal hemorrhoidal bleeding.

Colorectal neoplasia

Polyps or cancer can bleed and must not be missed by assuming hemorrhoids.

Proctitis

Inflammation may cause urgency, mucus, pain, or bleeding.

Rectal prolapse

Full-thickness or mucosal rectal prolapse differs from prolapsing hemorrhoidal cushions.

Perianal abscess

Progressive focal pain, swelling, fever, or systemic illness suggests infection.

Inflammatory bowel disease

Persistent diarrhea, urgency, abdominal symptoms, or systemic features need broader evaluation.

Clinical updates

Guideline patch notes

ASCRS 2024

American Society of Colon and Rectal Surgeons

Emphasizes a disease-specific history and examination, first-line dietary and behavioral measures, selective colon evaluation, and treatment matched to symptoms and anatomy.

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NIDDK patient reference

National Institute of Diabetes and Digestive and Kidney Diseases

Provides patient-facing descriptions of internal and external symptoms, home care, diagnosis, and reasons to seek medical care.

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Internal and external disease

Internal and external hemorrhoids are described relative to the dentate line. Internal disease commonly presents with painless bright-red bleeding or prolapse. External disease may cause irritation or swelling; a thrombosed external hemorrhoid can cause sudden, marked pain.

Assessment

Assessment begins with the bleeding pattern, prolapse, pain, bowel habit, medications, prior treatment, and colorectal risk factors. Inspection, digital rectal examination when appropriate, and anoscopy answer different questions. Colon evaluation is selective rather than automatic, but it should not be delayed when symptoms or screening status indicate it.

Treatment pathway

Conservative treatment is usually first. Selected internal hemorrhoids can be treated with office procedures, including rubber band ligation or injection sclerotherapy. Surgical treatment may provide more definitive control for substantial external disease, combined disease, advanced prolapse, or symptoms that persist despite less invasive care. [1]

Follow-up

Treatment success means improvement in the symptom that matters to the person, not simply changing a prolapse grade. Persistent or recurrent bleeding needs reassessment. Recovery planning should cover pain, bowel movements, expected minor bleeding, activity, urinary retention, infection warnings, and follow-up.