Colorectal, in full.

Nine GRADE recommendations (verified against the full text, Table 2). (1) A disease-specific history and physical examination should be performed, emphasizing the degree and duration of symptoms and risk factors (strong, low-quality evidence). (2) Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic hemorrhoids and rectal bleeding (conditional, low-quality); rectal bleeding should not automatically be attributed to hemorrhoids: colonoscopy is indicated when no obvious source of anorectal bleeding is observed or when associated abdominal symptoms (abdominal pain, distention, new-onset or progressive constipation) are reported at initial evaluation; patients with continued hematochezia after otherwise successful hemorrhoid treatment should undergo further investigation; patients due for colorectal cancer screening per consensus guidelines should be counseled appropriately. (3) Dietary and behavioral modifications are the primary first-line therapies for patients with symptomatic hemorrhoidal disease (strong, moderate-quality): increased fiber and fluid intake for all patients, plus counseling on bowel habits (avoid straining, limit time on the commode). (4) Medical therapy for hemorrhoids, while heterogeneous (topical creams, ointments, foams, and suppositories, including hydrocortisone, phenylephrine, pramoxine, and witch hazel, with limited supporting data; oral phlebotonics with Cochrane-level evidence of benefit for pruritus, bleeding, discharge, and overall symptoms but not pain), carries minimal harm and has the potential for symptomatic relief (conditional, low-quality). (5) Most patients with symptomatic grade I or II hemorrhoids and select patients with grade III hemorrhoids refractory to conservative treatment can be effectively treated with office-based procedures (rubber band ligation, injection sclerotherapy, infrared coagulation); hemorrhoid banding is considered the most effective office-based treatment (strong, moderate-quality). (6) Select patients with thrombosed external hemorrhoids may benefit from early surgical excision (conditional, low-quality); the guideline states there is no evidence regarding the optimal time period for nonoperative management, and that excision may yield faster symptom resolution, reduced recurrence, and longer remission intervals than incision with thrombus evacuation or topical 0.2% glyceryl trinitrate. (7) Excisional hemorrhoidectomy should typically be offered to select patients with external hemorrhoids or patients with symptomatic combined internal and external hemorrhoids, grades III-IV (strong, high-quality); it is also the approach for patients who fail, cannot tolerate, or are not candidates for office-based procedures. (8) Doppler-guided hemorrhoid artery ligation may be used for patients with internal hemorrhoids; compared with excisional hemorrhoidectomy it may result in decreased pain but increased recurrence rates (conditional, moderate-quality). (9) Stapled hemorrhoidopexy is not routinely recommended as a first-line surgical treatment for internal hemorrhoids given its marginal efficacy and significant risk profile (conditional, moderate-quality); the guideline documents higher recurrence than excisional surgery and unique complications including rectovaginal fistulas, staple-line bleeding and strictures, a 16.1% median complication rate with 5 documented mortalities in a 14,232-patient systematic review, and 40 published rectal perforations (2000-2009) with 4 deaths.