Question of the Day
Saturday, November 7, 2026
A 47-year-old man is evaluated for recurrent intermittent painless bright red blood that coats the stool and drips into the toilet over 4 months. He has no weight loss, abdominal pain, or change in stool caliber. A colonoscopy performed 8 months earlier for the same symptoms was normal to the cecum. He has increased dietary fiber and water intake and used sitz baths without relief. On examination, anoscopy shows nonprolapsing internal hemorrhoids that bleed on contact (grade 2); there are no fissures, masses, or external thrombosis. Which of the following is the most appropriate next step in management?
Answer: C. Rubber band ligation
Symptomatic grade 1-2 internal hemorrhoids that persist despite conservative measures (fiber, fluids, sitz baths) are best treated with an office-based procedure, and rubber band ligation is the most effective, requiring fewer repeat treatments than sclerotherapy or infrared coagulation. Continued conservative therapy alone (A) has already failed. Topical nifedipine (B) is used for anal fissures, not hemorrhoids. Excisional hemorrhoidectomy (D) is reserved for large grade 3-4 or refractory/thrombosed disease because of greater pain and recovery time. Repeat colonoscopy (E) is unnecessary because a complete normal examination was performed recently and the findings fully explain the bleeding. Pearl: for bleeding grade 1-2 internal hemorrhoids refractory to conservative therapy, rubber band ligation is the first-line office treatment.
Just show me the answer
Answer: C. Rubber band ligation
Symptomatic grade 1-2 internal hemorrhoids that persist despite conservative measures (fiber, fluids, sitz baths) are best treated with an office-based procedure, and rubber band ligation is the most effective, requiring fewer repeat treatments than sclerotherapy or infrared coagulation. Continued conservative therapy alone (A) has already failed. Topical nifedipine (B) is used for anal fissures, not hemorrhoids. Excisional hemorrhoidectomy (D) is reserved for large grade 3-4 or refractory/thrombosed disease because of greater pain and recovery time. Repeat colonoscopy (E) is unnecessary because a complete normal examination was performed recently and the findings fully explain the bleeding. Pearl: for bleeding grade 1-2 internal hemorrhoids refractory to conservative therapy, rubber band ligation is the first-line office treatment.
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