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H. Conclusions
Hemorrhoids are a common condition with symptoms that include bleeding, protrusion, and itching. Because other conditions can lead to identical symptoms, a directed physical examination, including anoscopy and proctosigmoidoscopy, should be performed.

Care depends on the extent of hemorrhoidal disease. First-degree hemorrhoids can be treated with medical management alone or with one of several nonoperative outpatient therapies. Second-degree and relatively small and thirddegree hemorrhoids can be treated with nonoperative therapy.

Surgery is generally reserved for the minority of patients who have large third-degree or fourth-degree hemorrhoids, acutely incarcerated and thrombosed hemorrhoids, hemorrhoids with an extensive and symptomatic external component, or patients who have undergone less aggressive therapy with poor results.

ROBERT D. MADOFF – University of Minnesota – Minneapolis, Minnesota

JAMES W. FLESHMAN – Washington University School of Medicine – St. Louis, Missouri

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Address requests for reprints to: Chair, Clinical Practice Committee, AGA National Of.ce, c/o Membership Department, 4930 Del Ray Avenue, Bethesda, Maryland 20814. Fax: (301) 654-5920.

The Clinical Practice Committee acknowledges the following individuals whose critiques of this review paper provided valuable guidance to the authors: Jeffrey L. Barnett, M.D., Peter Carne, M.D., Gary R.Lichtenstein, M.D., and John H. Pemberton, M.D.

The authors thank Pamela Barnard, M.S.L.S., for literature search assistance, Mary E. Knatterud, Ph.D., for editorial help, and Alexandra A. Broek for help with preparation of the manuscript.

Abbreviation used in this paper: MPFF, micronized, puri.ed .avonoid fraction.
© 2004 by the American Gastroenterological Association.

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