Chapter 03 — Haemorrhoids — Grading, BPRST, and Non-Surgical Mastery

Purpose: grade the haemorrhoids, exclude what they may be hiding, and match the treatment to the grade — fibre and toilet habits first, office procedures next, surgery last.

🎨 INFOGRAPHIC / VISUAL BLUEPRINT — CHAPTER 03

• Chapter colour palette: Crimson Red (#991B1B) header bar, Soft Rose (#FEF2F2) panels, Charcoal (#1F2937) text.
• Hero graphic: Dual-classification matrix aligning Goligher grades I–IV with BPRST stages I–III, a “no-phone commode” icon beside a fibre bowl, and a red siren panel for the post-banding pelvic sepsis triad (fever + worsening pain + urinary retention).
• Icon set: Fibre bowl, water glass, crossed-out phone, rubber band, infrared probe, syringe, red siren, colonoscope (alarm features).
• Bedside aphorism banner: “Leave the smartphone outside the bathroom. Fibre and short toilet visits are the cheapest haemorrhoid treatment there is.”

1. Classification: Goligher Plus BPRST

The Goligher classification grades internal prolapse only. Patients also present with bleeding alone, troublesome external tags, and acute thrombosis. The BPRST classification (Sobrado et al. 2020, 2021) adds these dimensions. Use both: Goligher for communication, BPRST to guide treatment.

Table 3.1 — Goligher classification and usual first-line approach

BPRST components and stages

• B — Bleeding: B0 none · B1 present.

• P — Prolapse: P0 none · P1 one pile prolapses · P2 two or more piles prolapse.

• R — Reduction: R0 spontaneous · R1 manual · R2 irreducible.

• S — Skin tags: S0 none · S1 symptomatic tags.

• T — Thrombosis: T0 none · T1 acute thrombosis.

Table 3.2 — BPRST stages and strategy

Evidence note: BPRST is a pragmatic staging system from one Brazilian group; external validation is limited [U]. Stapled haemorrhoidopexy is not recommended routinely as first-line surgery because of higher recurrence and rare serious complications (rectovaginal fistula, perforation, staple-line stricture, chronic tenesmus) (ASCRS 2024; AGA 2026).

2. First-Line Medical and Lifestyle Care (Every Grade, Every Patient)

1. Fibre and fluids [S]. Aim for 25–35 g of total dietary fibre per day. If a supplement is needed, start psyllium (ispaghula) at about 3.5 g once or twice daily and titrate over 1–2 weeks, each dose with a full glass of water. A meta-analysis of randomised trials found fibre roughly halved the risk of persisting symptoms (RR 0.53) and bleeding (RR 0.50) (Alonso-Coello et al. 2006). Warn about temporary bloating.
2. Toilet habits [C]. Respond to the first urge, avoid straining, and keep toilet visits to a few minutes — no phone or reading on the toilet. A footstool may help some patients [U].
3. Oral flavonoids (micronised purified flavonoid fraction, diosmin–hesperidin) [C][U]. May shorten acute bleeding and symptom episodes; licensed in many countries but not as a drug in the United States. Use short courses; evidence quality is modest.
4. Topical treatments [C]. Anaesthetics, astringents, corticosteroids, and vasoactive agents may give symptom relief but have little efficacy data. Limit topical corticosteroids to 2 weeks at a time (AGA 2026) to avoid atrophy, dermatitis, and infection.
5. Sitz baths [U]. Often advised, though data are limited (AGA 2026). Plain warm water is sufficient; avoid antiseptics such as chloroxylenol (Dettol) or povidone-iodine, which irritate anoderm.

3. Office Procedures: Matching the Tool to the Patient

Offer an office procedure when grade I–III internal haemorrhoids continue to bleed or prolapse after 4–6 weeks of conservative care (ASCRS 2024; AGA 2026). Obtain informed consent that includes the small risk of pelvic sepsis, and tell the patient to attend the ER immediately if warning symptoms develop (AGA 2026 [C]).

Table 3.3 — Office procedures

4. Special Populations

Table 3.4 — Special populations

5. Before Referral for Surgery, and After Haemorrhoidectomy

Pre-referral checklist

• Risk-based colonic evaluation (ASCRS 2024): age at or above the national screening start age without up-to-date screening (45 years in the United States; 50 in many other countries), iron-deficiency anaemia, altered bowel habit, weight loss, family history of colorectal cancer or IBD, or bleeding atypical for haemorrhoids → colonoscopy first (Chapter 08).

• IBD status — defer elective haemorrhoid treatment if active (AGA 2026).

• Antithrombotic plan, baseline continence, and pregnancy plans documented.

What to expect after haemorrhoidectomy (MDH energy-sealing standard) [C]

• Multimodal analgesia: regular paracetamol plus an NSAID unless contraindicated; topical metronidazole or diltiazem may reduce pain in some protocols; minimise opioids and always co-prescribe a laxative.

• Bowel care: stool softener (macrogol or lactulose) and fibre from day 1.

• Sitz baths: plain warm water, 10–15 minutes, 2–3 times daily and after bowel movements.

• Expected: spotting with bowel movements for several weeks.

• Seek help immediately for: bleeding soaking more than one pad per hour or passing clots; inability to pass urine for 6–8 hours, or painful bladder fullness; temperature above 38.0 °C; or pain that keeps worsening despite regular analgesia (Appendix D).

Algorithm 3.1 — Haemorrhoidal disease

[SYMPTOMS SUGGESTING HAEMORRHOIDS]
 History + inspection + DRE + anoscopy (every new patient)
|
+-- ALARM FEATURES? (at/after screening age and not screened,
|   iron-deficiency anaemia, weight loss, altered bowel habit,
|   family history of CRC/IBD, mass, persistent bleeding)
|     -> colon evaluation BEFORE blaming piles (Chapter 08)
|
+-- No alarm features -> classify (Goligher + BPRST)
    |
    +-- Grade I-II / BPRST I
    |     -> GREEN: fibre 25-35 g/day total + fluids + short
    |        toilet visits, no phone; topical steroid <= 2 wk
    |     -> still bleeding or prolapsing at 4-6 weeks?
    |          -> office procedure: RBL (most effective), or
    |             IRC / sclerotherapy if significant
    |             coagulopathy or antithrombotics continue
    |
    +-- Grade III / BPRST II
    |     -> YELLOW: RBL trial; surgical consultation if
    |        banding fails or large external component
    |
    +-- Grade IV, or BPRST III (R2, S1, or T1)
          -> do NOT band irreducible or thrombosed piles
          -> surgical referral (excisional haemorrhoidectomy;
             acute external thrombosis < 72 h: Chapter 02)

6. Dangerous Mimics — Things You Might Band by Mistake

Table 3.5 — Haemorrhoid mimics

7. Role-Targeted Action Boxes

🚑 ER DOCTOR ACTION BOX

• Two post-banding emergencies never to miss:
• 1 — Pelvic sepsis (usually within the first week): worsening perineal or pelvic pain + fever + urinary difficulty (sometimes nausea or faecal incontinence). Start the sepsis bundle, give broad-spectrum IV antibiotics covering Gram-negative and anaerobic organisms per local policy, and call the on-call surgeon for urgent examination under anaesthesia (ASCRS 2024; AGA 2026). Imaging must not delay surgical review.
• 2 — Delayed haemorrhage (typically days 5–10): caused by sloughing of the banded pedicle, especially if antithrombotics were restarted. Resuscitate; check full blood count, coagulation, and group-and-screen; call surgery for anoscopy and haemostasis. Balloon tamponade can bridge to definitive control [C].

🩺 FAMILY MEDICINE / GP CLINIC BOX

• Give a real conservative trial first (4–6 weeks of fibre, fluids, and toilet discipline) before referring grade I–II haemorrhoids.
• Know when banding is off the table: irreducible (R2) or thrombosed (T1) haemorrhoids, external tags (S1), significant coagulopathy, active IBD, and pregnancy.
• List all antithrombotics (aspirin, P2Y12 inhibitors, warfarin, DOACs) in the referral letter.

🏥 ER & WARD NURSE CARE AND SBAR BOX

• Voiding after surgery: encourage oral fluids and voiding; avoid excessive IV fluids once the patient is drinking [C]. If there is no void by 6–8 hours, or the bladder scan exceeds 400 mL with discomfort, escalate by SBAR for catheterisation.
• Discharge teach-back: the patient should repeat the three return triggers — heavy bleeding, cannot pass urine, fever or worsening pain.

💊 CROSS-SPECIALTY PRESCRIBING TRAP

• Repeat prescriptions of steroid haemorrhoid creams or suppositories: cap at 2 weeks at a time (AGA 2026). Steroids thin the anoderm, cause dermatitis and fungal infection, and never shrink a prolapsing cushion.
• Opioids after banding or surgery without a laxative produce hard stool that tears healing wounds.

⛔ NEVER DO THIS

• Never band irreducible (R2), acutely thrombosed (T1), or external haemorrhoids or skin tags.
• Never place a band at or below the dentate line.
• Never band a suspected rectal varix outside specialist care.
• Never prescribe topical steroids for more than 2 weeks at a time.
• Never attribute iron-deficiency anaemia to haemorrhoids before the colon (and, where indicated, the upper GI tract) has been examined.

📝 COMMON DOCUMENTATION ERROR

• “Piles” without a grade, anoscopy findings, and alarm-feature screen.
• No antithrombotic plan (which drug, stop date, restart date) before banding.
• Consent without pelvic sepsis listed as a risk, and no written return instructions (AGA 2026).

📨 REFERRAL URGENCY BOX

The Patient in Front of You — Chapter 03 Mini-Case

🧑‍⚕️ THE PATIENT IN FRONT OF YOU

A 49-year-old man comes to the ER 3 days after outpatient rubber band ligation of two grade II internal haemorrhoids. He has escalating deep pelvic pain, a temperature of 38.7 °C, and has been unable to pass urine for 8 hours despite a full bladder. The triage note reads “post-banding discomfort — for analgesia and discharge”.

Step 1 Spot the triad. Worsening pain + fever + urinary retention within the first week after banding is post-banding pelvic sepsis until proven otherwise — rare but potentially fatal.

Step 2 Resuscitate now. Do not reassure or discharge. IV access, blood cultures, lactate, full blood count, and broad-spectrum IV antibiotics (Gram-negative, anaerobic, and Gram-positive cover per local policy). Decompress the bladder with a catheter.

Step 3 Escalate. Call the on-call surgical consultant for same-day examination under anaesthesia, band removal, and drainage or debridement. CT can help define extent but must not delay surgical review.

Step 4 Document times: arrival, antibiotics, surgical call, theatre.

Board-Style Question — Chapter 03

A 54-year-old man with cirrhosis and portal hypertension has recurrent painless bright-red bleeding from grade II internal haemorrhoids despite 8 weeks of fibre. Anoscopy confirms internal haemorrhoids and no rectal varices; colonoscopy 6 months ago showed no other source. Platelets are 38 × 10⁹/L and INR is 2.3. Which office treatment is preferred?

• A. Rubber band ligation of all three columns
• B. Infrared coagulation
• C. Stapled haemorrhoidopexy
• D. Bedside excision of the haemorrhoids

Answer and explanation

• ❌ A Banding risks serious delayed bleeding when the pedicle sloughs; the AGA advises against it in significant coagulopathy.
• ✅ B Correct. The AGA 2026 Clinical Practice Update states that haemorrhoids in cirrhosis can be treated with banding or IRC, but that IRC is preferred in significant coagulopathy (platelets < 50 × 10⁹/L or INR > 2.0), and that portal hypertension alone should not change this approach.
• ❌ C Stapled haemorrhoidopexy is not a first-line operation (ASCRS 2024) and carries prohibitive bleeding risk here.
• ❌ D Excision is a surgical, not an office, treatment and is inappropriate for bleeding grade II haemorrhoids in uncorrected coagulopathy.

Ten-Item Rapid Revision Checklist — Chapter 03

• 01 I grade with Goligher and stage with BPRST.
• 02 I screen for alarm features and arrange colon evaluation before treating bleeding haemorrhoids.
• 03 I prescribe 25–35 g/day total fibre and titrate psyllium from about 3.5 g once or twice daily, with water.
• 04 I limit topical steroids to 2 weeks at a time.
• 05 I know RBL is the most effective office procedure.
• 06 I prefer IRC or sclerotherapy in significant coagulopathy or uninterruptible anticoagulation.
• 07 I never band R2, T1, external tissue, or varices.
• 08 I include pelvic sepsis in consent and give written return advice.
• 09 I can recognise the post-banding pelvic sepsis triad (worsening pain, temperature above 38.0 °C, urinary difficulty) and delayed haemorrhage.
• 10 I defer haemorrhoid procedures in active IBD and in pregnancy.

Five Most Dangerous Mistakes — Chapter 03

1. ⚠️ Discharging a patient with the pelvic sepsis triad as “post-banding discomfort”.
2. ⚠️ Treating bleeding “piles” in a patient with iron-deficiency anaemia without colon evaluation.
3. ⚠️ Banding a thrombosed, irreducible, or external haemorrhoid — or a varix.
4. ⚠️ Banding a patient on a DOAC or P2Y12 inhibitor without a peri-procedural plan.
5. ⚠️ Renewing steroid haemorrhoid creams month after month.

Suggested Figure and Table Captions for the Medical Illustrator — Chapter 03

• Figure 3.1. Goligher grades I–IV aligned with BPRST stages I–III.
• Figure 3.2. Correct band placement above the dentate line versus incorrect placement on anoderm.
• Figure 3.3. Red-siren panel: the post-banding pelvic sepsis triad and the day-5–10 delayed bleeding window.
• Table 3.1. Goligher classification and first-line approach.
• Table 3.2. BPRST stages and strategy.
• Table 3.3. Office procedures matched to patient factors.
• Table 3.4. Special populations.
• Table 3.5. Haemorrhoid mimics.
• Algorithm 3.1. Haemorrhoidal disease.