Hemorrhoids · Conservative vs Banding vs Surgery

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Goligher grade + thrombosis/external
   Internal hemorrhoid Goligher grade? Acute thrombosed external hemorrhoid?
   • Grade I (bleeding, no prolapse) → Grade I → conservative
   • Grade II (prolapse reduces spontaneously) → Grade II → rubber-band ligation
   • Grade III (prolapse needs manual reduction) → Grade III → banding or surgery
   • Grade IV (irreducible)/large mixed/recurrent → IV/large/recurrent → hemorrhoidectomy/PPH
   • Acute thrombosed external hemorrhoid → Acute thrombosed external hemorrhoid
2. [End] Grade I → conservative
   Grade I → conservative: high-fiber diet, hydration, improved bowel habits, warm sitz baths, topical agents; office sclerotherapy/banding may be added.
3. [End] Grade II → rubber-band ligation
   Grade II → rubber-band ligation (RBL, office procedure) ± conservative; can be repeated in sessions; watch for bleeding and pain afterward.
4. [End] Grade III → banding or surgery
   Grade III → rubber-band ligation or surgery; marked prolapse/banding failure → hemorrhoidectomy or stapled hemorrhoidopexy (PPH).
5. [End] IV/large/recurrent → hemorrhoidectomy/PPH
   Grade IV/large mixed/recurrent prolapse → hemorrhoidectomy (Milligan-Morgan/Ferguson) or stapled hemorrhoidopexy (PPH/stapled).
6. [End] Acute thrombosed external hemorrhoid
   Acute thrombosed external hemorrhoid → within <72 h with severe pain, excision of the thrombus/hemorrhoid gives rapid relief; otherwise conservative (analgesia, sitz baths, stool softeners), usually resorbs spontaneously.

Source guidelines & references

• Management of hemorrhoids (ASCRS clinical practice guideline; Goligher grading)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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