The Evaluation and Treatment of Hemorrhoids

A Guide for the Gastroenterologist

Robert A. Ganz


Clin Gastroenterol Hepatol. 2013;11(6):593-603. 

In This Article


The Lord will smite thee with … the emerods [hemorrhoids], and with the scab, and with the itch, whereof thou canst not be healed.
Deuteronomy 28:27, King James Bible
… and he smote the men of the city, both small and great, and they had emerods in their secret parts … and the men that died not were smitten with the emerods: and the cry of the city went up to heaven.
Samuel 5:1, King James Bible

Ancient references to symptomatic hemorrhoidal disease date back thousands of years and can be found in the Bible as well as early Egyptian, Babylonian, and Greek scripts.[1–3] The first known mention of this condition is from an Egyptian papyrus in 1700 BC, which advises … "Thou shouldest give an ointment of acacia leaves, ground and titurated together … and place in the anus, that he recovers immediately."[4] Indeed, there are few diseases more recounted in human history than hemorrhoids. The word hemorrhoid is derived from the Greek, with haima meaning blood and rhoos meaning flowing. Another common word for hemorrhoids used in the vernacular is "pile," which comes from the Latin pila, meaning a ball. As aptly noted by Senagore, "although few people have died of hemorrhoidal disease, many patients who have undergone certain hemorrhoid therapies wish they had," and this entity is one of the few diseases with its own patron saint (St Fiachre, the patron saint of gardeners and hemorrhoid sufferers).[1]

Symptomatic hemorrhoids are common, and those with hemorrhoids along with other anorectal diseases frequently present to the gastroenterologist with lower gastrointestinal (GI) bleeding and perianal complaints for evaluation and treatment. These patients and their referring physicians have an expectation that the gastroenterologist who examines this area should be able to provide comprehensive care of any nonsurgical anorectal ailments that are present. However, in large part because of the fact that formal training in anorectal pathology is not included in the combined Gastroenterology Core Curriculum, the care of these problems is often deferred to surgical specialties.[5,6]

There now seems to be an increasing recognition of this gap in the training of gastroenterology fellows, because an increasing number of GI programs are beginning to include nonsurgical anorectal care into their curricula. Some have called for the formal inclusion of anorectal entities into GI fellowship training.[5] It is the intent of this article to serve as a general introduction of the nonsurgical care of hemorrhoids to gastroenterologists, helping them provide a more complete continuum of care to their patients.