When rectal bleeding is due to hemorrhoids, treatment can often time be performed in the office setting.
Bleeding from Internal hemorrhoids is always painless. Bright red blood is seen after bowel movements and upon wiping. They can occur alone or in combination with external hemorrhoids. Internal Hemorrhoids originate from above the pectinate line (Ano-rectal junction)
Grade 1 hemorrhoids do not protrude from the rectum. Grade 2 hemorrhoids can protrude (prolapse), usually during BMs or straining, but spontaneously retract. Grade 3 hemorrhoids protrude and require manually pushing them back into the rectum. Grade 4 hemorrhoids are always outside of the rectum and can not be pushed back inside.
External hemorrhoids originate on the anal side of the pectinate line. These are always outside. External hemorrhoids can present with bleeding . or if they get filled with blood that clots, thrombosis which is excruciatingly painful. These are best treated by a colorectal surgeon as they generally require surgical resection if persistent.
Hemorrhoids grade 1 to 3 can be treated with banding. Depending on the size, this can either be done in the office with a 5 minute painless procedure, or in the Ambulatory Surgery Center with the help of a sigmoidoscope and sedation. A tiny rubber band (only a few millimeters wide) is placed over the base of an internal hemorrhoid to cut off the flow of blood. The hemorrhoid usually shrinks and falls off (along with the band) in about a week. Hemorrhoids are less likely to return with this method
thermal treatment is generally painless and effective for smaller hemorrhoids.
With this treatment, infrared light is applied above the hemorrhoid via an anoscope.The heat causes scar tissue to form cutting off blood flow to the hemorrhoid.
This is similar to infrared coagulation, except instead of an infrared light, heat from an electric current is used under endoscopic visualization. This can be done for small internal hemorrhoids at the time of a colonoscopy or flexible sigmoidoscopy.
When thermal techniques, and banding are ineffective in stopping the bleeding, or in the case of symptomatic or bothersome external hemorrhoids, patients are referred to a colorectal surgeon for surgical management.