Fig. 1.

Algorithm for the management of patients with suspected hemorrhoidal disease. ^a Colonoscopy is indicated in patients over the age of 50 years (earlier if there is family history of CRC or another condition predisposing to CRC) or if any alarm symptom is present; ^b consider using a symptom-based score, such as Sodergren score, to evaluate the severity of the HD; ^c advise avoiding excessive straining and limit the time at defecation; ^d medical management is enough for most patients. Some cases may require office-based treatment. RBL may be difficult to perform in such small vascular cushions; ^e the adopted type of surgical technique will depend on local expertise and should be a joint decision between the doctor and the patient; ^f studies have suggested a potential benefit of antibiotic prophylaxis in these patients owing to the risk of bacteremia after sclerotherapy; ^g there are no trials evaluating office-based therapies in pregnant women; therefore, they should probably be avoided during this period; ^h surgical treatment is effective in the prevention of recurrence and symptom control when applied during the first 48–72 h after symptoms onset. HD, hemorrhoidal disease; RBL, rubber band ligation; IRC, infrared coagulation.