Colorectal, in full.

Two current US documents now apply: ASCRS 2024 (GRADE-graded clinical practice guideline) and the AGA 2026 Clinical Practice Update (expert review, 11 best practice advice statements, no GRADE strength; Qureshi, Hoang, Frye, Rao; Clin Gastroenterol Hepatol, online April 29, 2026). Diagnosis: take a disease-specific history and exam. AGA advises anoscopy, whenever possible, for every new patient with suspected hemorrhoids before any treatment, to confirm the diagnosis and exclude other pathology including cancer. Do not automatically attribute rectal bleeding to hemorrhoids. Complete colonic evaluation is for select patients: no obvious anorectal bleeding source, associated abdominal symptoms or change in bowel habit, persistent hematochezia after successful treatment, or due for CRC screening. Grade internal hemorrhoids I-IV by prolapse. First line is diet and behavior: fiber (AGA cites 20-30 g/day) plus fluid, avoid straining, and limit toilet time (AGA cites about 3 minutes). Sitz baths have little evidence. Topical anesthetics, corticosteroids and vasoactive agents may give short-term relief on weak evidence; AGA limits topical corticosteroids to 2 weeks or less because of skin atrophy. ASCRS adds that oral phlebotonics help bleeding, pruritus and discharge but not pain. Office procedures come before surgery for grade I-III disease (ASCRS: grade I-II and select grade III refractory to conservative care). Rubber band ligation is the most effective office procedure (AGA: 66-94% success, more durable for prolapse and recurrent bleeding; about 2% complications). Infrared coagulation is comparable in the short term and preferred in anticoagulated patients, patients with coagulopathy or cirrhosis, and pregnant patients. Counsel every procedural patient on the rare risk of pelvic sepsis and its warning signs. Refer grade III disease refractory to office procedures, grade IV disease, and symptomatic combined internal/external disease for excisional hemorrhoidectomy, the definitive treatment. Doppler-guided artery ligation is an option (less pain, more recurrence). Stapled hemorrhoidopexy is not routinely first line (higher recurrence, unique serious complications). Special populations (AGA): in active Crohn's disease or UC, defer hemorrhoid treatment until remission; in pregnancy, treat conservatively and defer procedures until after delivery unless necessary; in cirrhosis, distinguish hemorrhoids from rectal varices. Acutely thrombosed external hemorrhoids: the two societies differ. ASCRS 2024 says select patients may benefit from early surgical excision, which beats incision/evacuation for recurrence. AGA 2026 says these are best treated surgically by incision and drainage, which relieves symptoms faster than nonoperative care (a secondary summary places this within 72 hours).