01Approach to the Critical Patient/attcp46

Immediate priorities

›Triage and stabilization

›Airway and breathing compromise uncommon

›Alternate diagnosis consideration if respiratory distress

›Hemodynamic instability

›If hypotension or syncope, alternate source of bleeding until proven otherwise

›Active brisk rectal bleeding

›If ongoing large volume hematochezia, lower GI bleed pathway

›Severe anal pain

›Thrombosed external hemorrhoid consideration

›Fever or systemic toxicity

›Perirectal abscess or sepsis pathway

High-risk features

›Red flags for serious pathology

›Weight loss

›Colorectal malignancy consideration

›Iron deficiency anemia symptoms

›Chronic GI blood loss workup

›Change in bowel habits

›Colitis or malignancy consideration

›Family history colorectal cancer or IBD

›Earlier endoscopic evaluation threshold

›Immunosuppression

›Infection and malignancy risk

›Anticoagulant or antiplatelet therapy

›Increased bleeding risk

Key concepts

›Hemorrhoidal disease framing

02History/hx48

Symptom profile

›Symptom characterization

›Bleeding pattern

›On paper

›Dripping into bowl

›Mixed with stool

›Pain pattern

›Sudden severe pain with lump

›Pain with defecation suggesting fissure

›Prolapse symptoms

›Tissue protrusion

›Spontaneous reduction

›Manual reduction

›Pruritus and moisture

›Soiling and mucus

›Bowel habit context

›Constipation

›Diarrhea

Risk factors and exposures

›Predisposing factors

›Low fiber diet

›Hard stools

›Prolonged toilet sitting

›Increased venous pressure

›Heavy lifting or Valsalva

›Symptom precipitation

›Pregnancy and postpartum

›Pelvic venous congestion

03Physical Exam/exam36

General and abdominal

›Systemic assessment

›Vital signs

›Hemodynamic instability markers

›Conjunctival pallor

›Anemia indicator

›Abdominal exam

›Tenderness or mass suggesting alternate source

Anorectal examination

›Perianal inspection

›External hemorrhoid

›Tender bluish perianal nodule suggesting thrombosis

›Skin tags

›Residual hemorrhoidal tags

›Fissure

›Posterior midline tear

›Abscess signs

›Erythema

›Fluctuance

›Digital rectal exam

›Sphincter tone

›Neurogenic concern if abnormal

›Mass

›Rectal cancer concern

›Tenderness

›Abscess concern

›Anoscopy if available and tolerated

›Internal hemorrhoids

04Differential Diagnosis/ddx25

Life-threatening or high-impact diagnoses

›Serious causes of hematochezia

›Colorectal cancer

›ICD-10 C18-C20

›Inflammatory bowel disease

›Ulcerative colitis ICD-10 K51

›Crohn disease ICD-10 K50

›Infectious colitis

›ICD-10 A04-A09

›Ischemic colitis

›ICD-10 K55

›Significant lower GI bleed

›Diverticular bleeding ICD-10 K57

Common mimics and coexisting conditions

›Anorectal mimics

›Anal fissure

›Severe pain with defecation

›Perianal abscess

›Fever and focal fluctuance

›Rectal prolapse

›Concentric folds

›Proctitis

›Tenesmus and mucus

›Anal cancer

›ICD-10 C21

›Dermatologic pruritus ani

›Irritant or fungal dermatitis

05Laboratory Tests/lt19

Core labs when indicated

›Bleeding risk assessment

›Complete blood count for significant bleeding concern

›Hemoglobin trend for ongoing bleeding

›Platelet count for coagulopathy screening

›Basic metabolic panel for dehydration concern

›Creatinine for medication and procedure planning

Coagulation and targeted tests

›Anticoagulation evaluation

›INR for warfarin use

›Supratherapeutic INR bleeding risk

›aPTT for heparin exposure

›Elevated aPTT bleeding risk

›Pregnancy testing when relevant

›Urine or serum beta hCG

›Pregnancy related management adjustments

Interpretation and limitations

›Lab caveats

›Normal hemoglobin early in acute bleeding

›Repeat testing if ongoing bleeding suspected

›Mild leukocytosis nonspecific

›Persistent fever and exam findings prioritize abscess workup

06Diagnostic Tests/dt40

Scoring Systems

›Hemorrhoid severity classification

›Goligher internal hemorrhoid grades

›Grade I bleeding without prolapse

›Grade II prolapse with spontaneous reduction

›Grade III prolapse requiring manual reduction

›Grade IV irreducible prolapse

›Clinical use

›Office procedures preferred for grade I to II and select grade III

›Surgical options for refractory grade III to IV

MRI

›Pelvic MRI roles

›Perianal fistula mapping when suspected

›Complex Crohn disease evaluation

›Deep abscess evaluation when exam equivocal

›Persistent fever and severe pain

›Neoplasm staging when suspected

›Anal or rectal cancer pathway

CT

›CT abdomen pelvis roles

›Alternate diagnosis evaluation

›Colitis features

›Diverticulitis features

›Perirectal abscess when severe pain and systemic signs

›Perirectal gas or collection detection

›Not a primary hemorrhoid test

›Hemorrhoids often not well characterized on CT

07Disposition/dispo23

ED and urgent referral decisions

›Immediate escalation triggers

›Hemodynamic instability or syncope

›Resuscitation and GI bleed pathway

›Ongoing large volume bleeding

›Admission and endoscopic evaluation consideration

›Severe pain with suspected thrombosed external hemorrhoid

›Urgent surgical evaluation consideration

›Fever or perianal fluctuance

›Abscess drainage pathway

Outpatient management suitability

›Discharge criteria

›Stable vital signs

›No orthostasis

›Minimal bleeding

›No anemia concern

›Pain controlled

›Oral regimen adequate

›Reliable follow-up

›Primary care or colorectal surgery access

Follow-up timing

›Follow-up targets

›Persistent symptoms after conservative trial

›Office procedure referral

›Recurrent bleeding or red flags

›Endoscopy referral pathway

08Treatment/t59

Conservative first-line measures

›Bowel habit optimization

›Dietary fiber increase

›Psyllium 5 g to 10 g daily to twice daily with fluids

›Titrate to soft formed stool

›Osmotic laxative for constipation

›Polyethylene glycol 17 g daily

›Titrate to one soft stool daily

›Avoid straining

›Toilet time limit

›Symptom relief

›Warm sitz baths

›10 to 15 minutes several times daily

›Topical anesthetic short course

›Lidocaine 2 percent topical per label

›Avoid prolonged use due to irritation risk

›Oral analgesia

›Acetaminophen 10 mg per kg to 15 mg per kg every 4 to 6 hours as needed

›Maximum 60 mg per kg per day

Pruritus and hygiene

›Skin care

›Gentle cleansing

›Water rinse or nonfragranced wipes

›Barrier protection

›Zinc oxide paste thin layer

›Avoid irritants

›Fragranced soaps

›Excess wiping

09Special Populations/sp25

Pregnancy

›Pregnancy considerations

›Increased risk in late pregnancy and postpartum

›Pelvic venous congestion and constipation

›Conservative measures prioritized

›Fiber and hydration

›Stool softening

›Medication safety review

›Prefer minimal topical exposure and short courses

›Referral for refractory severe disease

›Procedure timing individualized with obstetric input

Geriatric

›Older adult considerations

›Higher baseline colorectal cancer risk

›Lower threshold for colon evaluation with bleeding

›Polypharmacy effects

›Constipation from anticholinergics and opioids

›Anticoagulation common

›Bleeding risk stratification and coordination with prescriber

Pediatrics

›Pediatric considerations

›Hemorrhoids uncommon

›Alternate diagnosis consideration if bleeding

›Constipation predominant etiology when present

›Behavioral toileting plan

›Polyethylene glycol weight-appropriate regimen

›Child protection awareness

›Consider trauma only when history or exam suggests

10Background/b20

Epidemiology

›Frequency and burden

›Common anorectal condition

›Population prevalence estimates reported up to about 39 percent in some studies

›Age distribution

›Symptomatic disease more common in adults

Pathophysiology

›Mechanistic overview

›Normal anal cushions vascular tissue

›Contribution to continence

›Symptomatic disease mechanisms

›Cushion displacement and enlargement

›Venous congestion and connective tissue deterioration

›Thrombosis mechanism

›Clot formation in external plexus with acute pain

Therapeutic Considerations

›Treatment principles

›Constipation control reduces symptoms and recurrence

›Fiber as foundational therapy

›Office procedures address internal hemorrhoids

›Banding often most effective office-based option

›Surgical therapy for advanced or refractory disease

›Balance recurrence versus pain and complications

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge guidance

›Bowel regimen

›Daily fiber supplement with plenty of water

›Polyethylene glycol daily if stools hard

›Symptom relief

›Warm sitz baths 10 to 15 minutes

›Gentle cleansing and barrier cream

›Activity and toileting

›Avoid straining

›Limit time on toilet

›Expected course

›Mild bleeding may persist briefly

›Pain should improve over days with soft stools

›Return to ER now

›Heavy bleeding

›Dizziness or fainting

›Black stools

›Fever

›Worsening severe anal pain

›New swelling with redness or drainage

›Follow-up

›Primary care if symptoms not improving within 7 to 14 days

›Colorectal surgery referral if recurrent bleeding or prolapse

12References/r13

Clinical guidelines

›Guideline sources

›ASCRS Clinical Practice Guidelines for Management of Hemorrhoids 2024

›Office-based procedures for grade I to II and select grade III refractory to conservative therapy

›Rubber band ligation considered most effective office-based treatment

›NICE interventional procedure guidance on hemorrhoidal artery ligation

›Mentions banding and sclerotherapy as interventional options

Evidence-based sources

›Key evidence and reviews

›Review literature on thrombosed external hemorrhoid timing

›Symptom peak around 48 hours and benefit of early intervention within about 72 hours in select patients

›Primary care evidence summary on thrombosed hemorrhoid procedures

›Excision or evacuation within 72 hours can provide faster pain relief

›Patient-facing reference for procedure overview

›Rubber band ligation mechanism and typical time to slough

Evidence & Review

Evidence & Review