Colorectal Surgery & Gastroenterology & Family Medicine & Proctology
Hemorrhoids
Hemorrhoids are normal vascular structures of the anal canal - submucosal cushions composed of anastomosing arteriovenous vessels, loose connective tissue and smooth muscle fibers - whose physiological function is to contribute to fine anal continence and the tightness of the anal canal at rest. Hemorrhoidal disease occurs when these pads become symptomatic due to engorgement, prolapse or thrombosis. With an estimated prevalence of 38-39 % of the adult population in the United States (Johanson 1990 - American Journal of Surgery), and probably a similar figure in Canada, hemorrhoidal disease is one of the most common colorectal disorders, accounting for over 4 million annual medical consultations in North America. Anatomically, internal hemorrhoids are located above the pectineal (or serrated) line, submucosal and insensitive to pain, while external hemorrhoids are located below this line, subcutaneous and innervated by somatic fibers sensitive to pain. Contributing factors include chronic constipation with prolonged defecation, chronic diarrhoea, pregnancy, obesity, sedentary lifestyle, low-fibre diet, prolonged sitting and genetic predisposition. Management is graded: hygienic-dietary measures and topical treatments for mild forms, in-office procedures (elastic ligation, sclerosis) for moderate forms, and surgery (hemorrhoidectomy or hemorrhoidopexy by stapling) for severe or refractory forms.
Anatomy, classification, and pathophysiology
- Anatomy of hemorrhoidal cushions and pathophysiology of the disease: normal anatomy: hemorrhoidal pads = normal vascular structures present in all individuals → located mainly in 3h, 7h and 11h position (dorsal lithotomy position) → composed of : arteriovenous anastomoses (direct artery-vein shunts without capillary bed) + anchoring connective tissue (Parks fibers and elastic fibers connecting the pad to the internal sphincter and longitudinal muscle) + smooth muscle cells → physiological role: fine continence → contribution to anal sealing (pads fill irregularities in the anal canal) → Haas 1984 - Diseases of the Colon and Rectum : hemorrhoidal pads contribute 15-20 % of anal canal resting pressure; pathophysiology of hemorrhoidal disease - two main theories: vascular theory: arterial hyperflux → engorgement of anastomoses → turgidity of pads → Aigner 2004 - Diseases of the Colon and Rectum: Doppler of hemorrhoidal vessels → increased arterial flow in symptomatic vs. asymptomatic hemorrhoids → basis of Doppler-guided hemorrhoidal artery ligation technique (HAL-RAR) → mechanical theory (currently dominant): degradation of connective tissue anchoring pads → downward sliding (ptosis) → prolapse → leads to dilated veins → Loder 1994 - British Journal of Surgery: Parks fibers are fragmented and stretched in grade III-IV hemorrhoids → aging + repeated efforts + chronic trauma (defecation efforts) → progressive degradation of anchoring fibers → prolapse; favoring factors: chronic constipation + prolonged defecation efforts (≥10 min to the toilet) → increased abdominal pressure → downward displacement of the pads → chronic diarrhea (irritation + repeated hyperpressure) + pregnancy: compression of inferior vena cava + portal hypertension of pelvic veins + progesterone → relaxation of connective tissues + expulsive efforts → 25-35 % of pregnant women develop symptomatic hemorrhoids + obesity + sedentary lifestyle + low-fiber diet + prolonged sitting (toilet + sedentary work) + portal hypertension (cirrhosis) → engorgement of porto-cava anastomoses in the anal plexuses → hemorrhoids secondary to PHT + genetic predisposition (constitutional weakness of connective tissue) ; classification of internal hemorrhoids - stage of disease (Goligher Grade 1975): grade I: bleeding without prolapse → grade II: prolapse during defecation + spontaneous reintegration → grade III: prolapse + manual reintegration necessary → grade IV: permanent prolapse not reintegrable → external hemorrhoids: localized below the pectineal line + innervated + painful + external hemorrhoidal thrombosis (formerly «perianal subcutaneous hematoma»): acute painful complication
- Clinical presentation and differential diagnosis: symptoms of hemorrhoidal disease: rectorrhagia: bright red blood + during defecation + on paper or in bowl (not mixed with stool - unlike high rectorrhagia) + never melena in hemorrhoidal disease → anal pruritus: chronic irritation by mucous secretions in case of prolapse + mucous oozing: hemorrhoidal prolapse with mucous secretion → soiling + discomfort + prolapse felt as an anal «ball» + heaviness + chronic discomfort + pain: internal hemorrhoids are insensitive → pain = external hemorrhoidal thrombosis (intense acute pain + firm perianal blue swelling) → or associated anal fissure → or anal abscess → intense anal pain without visible thrombosis → look for fissure + abscess + fleeting proctalgia + anal incontinence (associated if massive grade IV prolapse); clinical diagnosis - proctological examination: anorectal inspection: left lateral decubitus (Sims position) or dorsal decubitus (gynecological) → visualization of external hemorrhoids + prolapse → rectal examination (RE): does not palpate internal hemorrhoids (too soft) → but excludes a palpable mass + assesses sphincter tone + anuscopy: direct visualization of internal hemorrhoids → rigid 6-8 cm tube + lumen → confirms grade + localizes hemorrhoids + assesses mucosa + eliminates differential diagnoses (polyps + fissures) + rectosigmoidoscopy or colonoscopy: to be performed systematically if rectorrhagia in a patient ≥40-45 years + family history of colorectal cancer + iron-deficiency anemia + persistent rectorrhagia despite hemorrhoidal treatment → never attribute rectorrhagia to hemorrhoids without ruling out colorectal cancer in patients at risk; differential diagnosis of hemorrhoids - not to be missed: cancer of the rectum or anal canal → always examine + complete rectal prolapse → prolapse of the entire rectal wall + anal fissure → pain + bright red blood + hyperalgesia on TR + anorectal abscess + anorectal fistula + anorectal condylomas (HPV) + ulcerative proctitis + marisci (residual + painless + non-vascular skin folds)
Treatment and care
| Stage / intervention | Modalities, techniques, and results | Evidence and recommendations |
|---|---|---|
| Medical treatment and hygienic-dietary measures — grades I–II Fibers — hydration — laxatives — topicals — phlebotonics — flavonoids — MPFF — pain relief |
Hygienic-dietary measures - basic treatment of all grades: increase dietary fiber: target 25-35 g/d → green vegetables + legumes + whole grains + psyllium (Metamucil) + methylcellulose + fiber supplements reduce hemorrhoidal symptoms by 50 % (Alonso-Coello 2006 - American Journal of Gastroenterology: meta-analysis of 7 RCT trials → fiber → reduction in bleeding and prolapse by 47-54 % vs placebo) + hydration: 1.5-2 L/d → softening of stools + reduction of straining + avoid prolonged straining: don't stay in the toilet for more than 3-5 min + avoid reading or using the phone in the toilet + don't strain + optimal defecation position: elevation of feet (stool under feet - squatting position - Bliss 2001 - Gastroenterology Nursing) → improves anorectal angle → facilitates effortless defecation → physical activity: reduced constipation + improved transit + venotonic improvement; topical treatments - symptomatic relief of grades I-III: topical corticoids (hydrocortisone + prednisolone): reduction of inflammation and pruritus → effective in the short term + risk of skin atrophy if prolonged use >2 weeks → use for short periods → local anesthetics (lidocaine + benzocaine): reduction of pain and itching + zinc-based creams + moisturizing and protective treatments (zinc oxide + vaseline + Preparation H) → reduction of oozing + protection of perianal skin → astringents (witch hazel + alum): reduction of oedema + oozing → suppositories: less effective than creams (rise too high in the rectum) + overall modest efficacy data for topicals (most studies without validated placebo); phlebotonics - micronized purified flavonoid fraction (MPFF - Daflon 500 mg / Ardium): mixture of micronized diosmin (90 %) + hesperidin (10 %) → mechanism: increased venous tone + reduced capillary permeability + anti-inflammatory properties (prostaglandin inhibition) + reduced terminal arterial flow → Cospite 1994 - Angiology: MPFF 500 mg 2×/d × 8 weeks → reduced bleeding by 67 % + reduced prolapse + pain → Alonso-Coello 2012 - Cochrane Database: meta-analysis of 24 trials (n=2,344 patients) → phlebotonics → 67 % reduction in bleeding + 47 % reduction in pruritus + 40 % reduction in prolapse + 65 % reduction in recurrences after ligation → Daflon = reference phlebotonic → best-documented efficacy among phlebotonics → Perera 2012 - Colorectal Disease: Daflon + elastic ligation → reduced post-ligature complications and recurrences → triphala + ruscus aculeatus (butcher's broom) + hydroxethylrutosides: less efficacy + fewer quality studies; treatments for acute attack of external hemorrhoidal thrombosis: conservative treatment (if >72h since onset or tolerable pain): systemic NSAIDs (ibuprofen 400-600 mg × 3/d × 5-7d) + anesthetic cream (lidocaine gel) + lukewarm water sitz baths × 3-4/d × 15 min + MPFF (Daflon) + edema reduction → relief in 7-10 days + percutaneous thrombectomy or in-office excision (if <72h since onset + intense pain): radial incision or simple excision under local anesthesia (lidocaine 1-2 % + or bupivacaine) → evacuation of clot → immediate pain relief → Greenspon 2004 - Diseases of the Colon and Rectum: excision vs simple incision within 72h → superior complete excision (reduced recurrences: 6 % vs 25 %) → better 2-year results for complete excision | Key data on medical treatment: Alonso-Coello 2006 - American Journal of Gastroenterology: meta-analysis 7 RCTs fibers → reduction of 47-54 % bleeding + reduction of recurrences + reduction of interventions → fibers = most effective baseline measure → Alonso-Coello 2012 - Cochrane: phlebotonics → meta-analysis 24 trials n=2,344 → reduction 67 % bleeds + 47 % pruritus + 65 % recurrences → MPFF (Daflon) = most effective systemic medical treatment → Cospite 1994 - Angiology: RCT Daflon vs placebo → 67 % bleeding reduction → Greenspon 2004 - Diseases of the Colon and Rectum: excision vs incision hemorrhoidal thrombosis → superior excision → recurrence rate 6 % vs 25 % → Bliss 2001 - Gastroenterology Nursing: squatting position → improved defecatory effort → reduced hemorrhoidal symptoms; reimbursement in Quebec (RAMQ): fiber supplements (psyllium): partially available without prescription + MPFF (Daflon): not reimbursed by RAMQ (available in pharmacies without prescription) + NSAIDs + analgesics: reimbursed under the usual conditions |
| Office Procedures — Elastic Band Ligation, Sclerosis, and Infrared Coagulation — Grades I–III Elastic band ligation — sclerotherapy — infrared photocoagulation — results — complications — comparisons |
Elastic ligation of internal hemorrhoids (rubber band ligation - RBL) - reference outpatient treatment: principle: application of a rubber band to the base of an internal hemorrhoid (above the pectineal line - insensitive area) → strangulation of the vascular pedicle → ischemic necrosis → hemorrhoid falls off at D5-J10 + fixation of residual mucosa → technique: anuscope + ligation forceps or suction ligator (McGivney) → 1-3 hemorrhoids per session → apply elastic at least 1-2 cm above the pectineal line (intense pain if too low) → sessions spaced 4-6 weeks apart if several ligations → results: short-term success rate: 70-80 % for grades II-III → recurrence at 5 years: 30-70 % (depending on grade and follow-up) → Peng 2003 - Diseases of the Colon and Rectum: meta-analysis → RBL superior to infrared photocoagulation and sclerotherapy for grades II-III → RBL success rate: 75-80 % vs IR: 65-70 % vs sclerotherapy: 55-65 % + Shanmugam 2005 - Cochrane: RBL more effective than sclerotherapy for grades II-III (OR 3.7 for symptom resolution) → complications of RBL: post-procedure pain: mild to moderate (although the area is insensitive → visceral pain reflex) → 2-5 days + sitz baths + NSAIDs → bleeding at the time of rubber band drop (D5-J10): often slight → rarely significant → associated external hemorrhoidal thrombosis: 2-3 % → urinary retention: 1-2 % → intraoperative vasovagal syndrome → serious complications rare but worth knowing about: perianal sepsis (infected necrosis - cellulitis + necrotizing fasciitis) → <0.5 % → mortality described → consult urgently if fever + intense anal pain + sepsis in the days following an RBL → immediate surgical advice + contraindications to RBL: anticoagulants + coagulation disorders + severe immunodepression + active inflammatory bowel disease + pregnancy; sclerosis by injection of phenol (or other sclerosant): injection of phenol 5 % in vegetable oil (or polydocanol) at the base of the hemorrhoid → fibrosis + tissue sclerosis → main indication: grade I with bleeding + anticoagulated patient (RBL contraindicated) → results inferior to RBL for grades II-III → short-term efficacy: 50-70 % → high recurrence rate → complications: prostatitis if injection too deep in men → abscess → injection into anal mucosa rather than submucosa → infrared (IR) photocoagulation: infrared beam → coagulation of tissue → fibrosis → indication: grade I-II with mild bleeding + anticoagulated patients → results inferior to RBL → efficacy 65-70 % → less post-procedural pain → can be repeated more easily → Johanson 1992 - Diseases of the Colon and Rectum: IR vs RBL → IR less effective but better tolerated → cryo-hemorrhoidectomy and hemorrhoidolysis by bipolar electrocoagulation: less-used alternatives + HAL-RAR (Hemorrhoidal Artery Ligation with Recto-Anal Repair): Doppler-guided ligation of upper hemorrhoidal arteries + mucopexy (suture reattachment of mucosal prolapse) → grade II-III → similar efficacy to hemorrhoidectomy for grade III without significant prolapse + less painful + Ratto 2015 - British Journal of Surgery: HAL-RAR → similar results to surgery + less pain + more frequent recurrence in the long term | Comparative data between in-office procedures: Peng 2003 - Diseases of the Colon and Rectum (meta-analysis): RBL superior to IR and sclerosis for grades II-III → overall success rate: RBL 75-80 % vs IR 65-70 % vs sclerosis 55-65 % → RBL = reference outpatient procedure + Shanmugam 2005 - Cochrane Database of Systematic Reviews: RBL vs sclerosis → RBL: OR 3.7 for symptom resolution → significant difference → Ratto 2015 - British Journal of Surgery: HAL-RAR vs hemorrhoidectomy → equivalent results at 1 year → less pain + faster return to work → more frequent recurrence at 3 years (21 % vs 12 %) → pain/recurrence trade-off to be discussed with patient → Johanson 1992 - Diseases of the Colon and Rectum: IR vs RBL → IR less painful but less effective → preferential indication in grades I-II in patients not tolerating RBL; rare but serious complications of RBL - mortality data : Bat 1993 - Diseases of the Colon and Rectum: post-RBL sepsis → necrotizing fasciitis → mortality in reported cases → surgical emergency → presentation: fever + severe anal pain + perineal edema within 48-96h post-procedure → indication for surgical exploration without delay |
| Hemorrhoid surgery — grades III–IV and refractory forms Hemorrhoidectomy: Milligan-Morgan, Ferguson, Stapling (PPH), THD - Postoperative Pain - Complications - Long-Term Outcomes |
Surgical indications: grades III-IV refractory to conservative treatments + grade III bulky from the outset + mixed hemorrhoids (internal + external) + complicated hemorrhoidal thrombosis + uncontrollable hemorrhage + repeated failure of ligatures + patient preferring definitive resolution → Milligan-Morgan open hemorrhoidectomy (gold-standard technique): en bloc resection of the three main hemorrhoidal pedicles (3h, 7h, 11h) + pedicle ligation + wounds left open (healing by second intention) → advantages: maximum efficacy + durability + 10-year recurrence rate: 5-10 % → disadvantages: intense postoperative pain (main cause of morbidity - EAN - well innervated painful area if wounds extend below the pectineal line) + long healing (4-8 weeks) + return to work: 2-4 weeks + risk of anal stenosis (if too much mucosa resected - rule: leave mucosal bridges between wounds) + Ferguson closed hemorrhoidectomy (American procedure): resection + immediate suturing of wounds → faster healing + slightly reduced pain → similar complication rates → less used in Canada; postoperative pain - central problem of hemorrhoidal surgery: mechanisms: exposure of anal mucosa sensory fibers + internal sphincter spasm → multimodal pain protocol recommended: NSAIDs (ketorolac + naproxen) + paracetamol (4 g/d) + AAGABA (pregabalin - reduction of neuropathic pain) + pudendal nerve block intraoperatively + perianal subcutaneous injection of long-acting bupivacaine → intrasfincterian injections of botulinum toxin A (BTX-A): reduction of internal sphincter spasm → reduction of postoperative pain by 30-40 % (Patti 2006 - Diseases of the Colon and Rectum: BTX-A + hemorrhoidectomy → pain reduction at D1 + D7 + acceleration of healing) → oral metronidazole (400 mg × 3/d × 7d): local anti-inflammatory effect → pain reduction of 30 % (Carapeti 1998 - British Journal of Surgery) + sitz baths × 3/d → osmotic laxatives (macrogol - Lax-A-Day) → stool softening → pain reduction on defecation; circular stapling hemorrhoidopexy (PPH - Procedure for Prolapse and Hemorrhoids - Longo stapling): circular resection of the supra-hemorrhoidal rectal mucosa → mechanical realignment of prolapsed pads + interruption of arterial flow → less painful than conventional hemorrhoidectomy (resection above the pectineal line - insensitive area) → Longo 1998 - original technique → Tjandra 2007 - Diseases of the Colon and Rectum: meta-analysis → PPH vs Milligan-Morgan → PPH: less pain + faster return to work (7 vs. 14 days) + similar short-term functional results → but: higher long-term recurrence rate (10-20 % vs. 5-10 %) + rare but serious complications: rectal perforation + recto-vaginal fistula + anal stenosis + persistent defecatory urgency → select grades III with moderate prolapse → not for bulky mixed hemorrhoids → HAL-RAR (see previous section): minimally invasive + resection-free surgical alternative → grade II-III + long-lasting results for grades II but higher recurrence rate than conventional surgery for grades III-IV; complications of hemorrhoidectomy: early postoperative hemorrhage (D0-J24h): 1-2 % → surgical or endoscopic hemostasis → secondary hemorrhage (D7-J14) → eschar fall → 1-3 % → often resolves spontaneously → transient urge-incontinence: sphincter spasm + secretions → 5-10 % → resolves → true anal incontinence: very rare if correct technique (<1 %) → anal stenosis: if too much mucosa resected or without sufficient skin bridges → prevention → acute urinary retention (most frequent): 10-20 % → management by short catheterization + reduction of intraoperative IV filling + abscess / perianal sepsis: <1 % | Fundamental data on hemorrhoidal surgery: Tjandra 2007 - Diseases of the Colon and Rectum (meta-analysis 25 RCTs PPH vs Milligan-Morgan): PPH → less pain + faster return to work → but more frequent recurrence in the long term → recommended for grades III without bulky external hemorrhoids + Jayaraman 2014 - Cochrane (meta-analysis): stapled hemorrhoidopexy vs conventional hemorrhoidectomy → PPH less painful + recurrence + residual prolapse more frequent → indication limited to grades III without complexity + Patti 2006 - Diseases of the Colon and Rectum: BTX-A intraoperatively → pain reduction at D1 and D7 + accelerated healing → Carapeti 1998 - British Journal of Surgery: oral metronidazole posthemorrhoidectomy → pain reduction of 30 % at D7 + Ratto 2015 - British Journal of Surgery: HAL-RAR vs hemorrhoidectomy → equivalent results at 1 year → less pain + more recurrences at 3 years (21 % vs 12 %) → compromise to be individualized + Loder 1994 - British Journal of Surgery: fragmented Parks fibers in grades III-IV → pathophysiological basis for surgery + Johanson 1990 - American Journal of Surgery: hemorrhoid prevalence USA: 38.9 % → 4.4 million consultations/year → major public health impact; long-term results of conventional hemorrhoidectomy: 10-year recurrence rate: 5-10 % → most durable treatment → 1-year patient satisfaction rate: 85-95 % → recommended for refractory grades III + grade IV + bulky mixed hemorrhoids + patient preferring definitive solution |
| Hemorrhoids in Special Situations - Pregnancy, Anticoagulants, IBD, Immunosuppression, and Follow-up Pregnancy — childbirth — anticoagulants — Crohn's — HIV — portal vein — anal Crohn's — relapses — follow-up |
Hemorrhoids in pregnancy and postpartum: prevalence: 25-35 % of pregnant women → majority in 3rd trimester + aggravation during labor and delivery → treatment in pregnancy: fiber + hydration + sitz baths + Daflon (MPFF) 500 mg 2×/d: can be used during pregnancy (Cospite 1994 + safety studies - Daflon is classified as can be used after 1st trimester based on available data - consult physician) → topical creams: low-dose hydrocortisone (short duration) + local anesthetics (lidocaine - avoid essential oils + potentially absorbable benzocaine derivatives) → invasive procedures (RBL + surgery): avoid during pregnancy except in emergencies + hemorrhoidal thrombosis in pregnancy: conservative (NSAIDs contraindicated after 24 SA - paracetamol) + sitz baths + if painful and 200 + undetectable viral load → acceptable standard procedures → CD4 <200 or severe immunodepression → risk of poor healing + opportunistic infections → surgery to be avoided → sclerosis or conservative measures → hemorrhoids on portal hypertension (cirrhosis): secondary hemorrhoids → aggravated by coagulopathy + thrombocytopenia + PHT → high bleeding risk → strict medical treatment (fibers + Daflon) + parallel esophageal varicose vein prophylaxis (beta-blockers + TIPS as indicated) → anorectal varices (to be distinguished from hemorrhoids) are not treated by the same techniques; follow-up of hemorrhoidal disease after treatment: no systematic follow-up necessary if complete resolution of symptoms → preventive measures to be maintained for life: fiber + hydration + lifestyle + if recurrence: assess grade + resume therapeutic cascade according to grade → colonoscopy if persistent bleeding + age ≥45 years or risk factor for colorectal cancer → post-surgical recurrences (5-10 % at 10 years): re-intervention possible (repeat hemorrhoidectomy or RBL of isolated recurrences); warning signs requiring full colorectal investigation (colonoscopy) despite diagnosis of hemorrhoids: rectorrhagia in a patient ≥45 years + persistent change in bowel habits + involuntary weight loss + iron-deficiency anemia + family history of colorectal cancer or polyps + persistent bleeding despite well-conducted hemorrhoidal treatment | Data on special situations and follow-up: Cospite 1994 - Angiology: MPFF (Daflon) in pregnancy → documented safety + efficacy → reduction in bleeding and symptoms + Greenspon 2004 - Diseases of the Colon and Rectum: excision of thrombosis within 72h → recurrence 6 % vs incision alone 25 % → at 2 years: significantly better results for complete excision + Alonso-Coello 2012 - Cochrane: phlebotonic + post-RBL → reduced complications and recurrences → indication to combine Daflon and RBL in patients at risk of recurrence → MacRae 1997 - Diseases of the Colon and Rectum: Cochrane on hemorrhoidal procedures → RBL = most effective outpatient procedure for grades II-III + best efficacy/cost ratio + Bat 1993 - Diseases of the Colon and Rectum: post-RBL sepsis → description of cases of necrotizing fasciitis + mortality → alert to the most serious complication of RBL → presentation within 48-96h → surgical emergency + Canadian Association of Gastroenterology 2019 (rectorrhagia): any rectorrhagia in a patient ≥45 years → colonoscopy to be performed within 6-8 weeks + never attribute rectorrhagia solely to hemorrhoids without having ruled out colorectal cancer |
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Never attribute rectal bleeding to hemorrhoids without first ruling out colorectal cancer in at-risk patients: Hemorrhoids and colorectal cancer can coexist and present with similar symptoms (bright red blood in the stool). Any patient 45 years or older with new rectal bleeding, any persistent change in bowel habits, unexplained weight loss, or iron deficiency anemia should undergo a colonoscopy, regardless of the presence of confirmed hemorrhoids. Hemorrhoids do not protect against colorectal cancer.
Situations requiring urgent medical attention
Intense anal pain + blue, hard, and painful swelling at the anus, which appeared suddenly → acute external hemorrhoid thrombosis → medical consultation within 24–72 hours → if <72 hours from onset + severe pain → thrombectomy or excision under local anesthesia → immediate relief → beyond 72 hours → conservative treatment (NSAIDs + Daflon + sitz baths) → regression in 7–10 days.
Fever + intense anal pain + peri-anal edema + redness in the days following a rubber band ligation or hemorrhoidectomy Perianal sepsis + risk of necrotizing fasciitis → Surgical emergencies → Call 911 if signs of systemic sepsis → Infectious workup + emergency perineal CT scan → Urgent surgical exploration → High mortality without immediate management.
Heavy rectal bleeding with bloody stools or clots, paleness, weakness, and rapid heart rate → Significant lower gastrointestinal bleeding → medical emergencies → DO NOT attribute to hemorrhoids without evaluation → biological assessment + colonoscopy or CT scan urgently depending on hemodynamic stability.
Irreducible hemorrhoidal prolapse with massive edema and color change (purple, blackish) incarcerated prolapse with risk of necrosis → surgical emergency → manual reduction under sedation + emergency surgery if irreducible → ice + anesthetic ointment while awaiting medical evaluation.
Consult at Clinique Omicron
Clinique Omicron physicians evaluate hemorrhoidal disease, initiate appropriate hygienic-dietary measures and medical treatments based on grade, prescribe suitable phlebotonics and topical treatments, refer to a gastroenterologist or colorectal surgeon for in-office procedures (elastic band ligation) or surgery depending on severity, and provide post-treatment follow-up. Consultations are available at multiple service points in Quebec and via telemedicine. To book an appointment, visit cliniqueomicron.ca.
The content of this page is for informational purposes only and does not replace the advice of a doctor or colorectal surgeon. Any rectal bleeding requires medical evaluation to rule out colorectal cancer, regardless of the known presence of hemorrhoids.
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