What the 2026 AGA hemorrhoid update says — and why not every anal symptom is a hemorrhoid
A new American Gastroenterological Association Clinical Practice Update puts fibre, fluids and not straining first for symptomatic hemorrhoids, reserves procedures and surgery for higher grades — and is a reminder that bleeding from the bottom should be checked, not assumed.
A new American Gastroenterological Association Clinical Practice Update puts fibre, fluids and not straining first for symptomatic hemorrhoids, reserves procedures and surgery for higher grades — and is a reminder that bleeding from the bottom should be checked, not assumed.
Sources
Hemorrhoids are one of those topics people rarely talk about and often quietly self-diagnose. They are extremely common, and most of the time they are not serious. But "common and usually harmless" is exactly the situation where a clear, sourced summary is worth having — both so you know what genuinely helps, and so you know which symptoms should not be brushed off as "just piles."
In April 2026, the American Gastroenterological Association published a Clinical Practice Update on diagnosing and treating hemorrhoids. Here is what it says, set alongside NHS patient guidance.
What hemorrhoids actually are
Hemorrhoids — also called piles — are swollen blood vessels in or around the anus and lower rectum. NHS guidance describes them as very common and notes they often settle on their own within a few days. The standard self-care advice is unglamorous but consistent: drink plenty of fluids, eat more fibre to keep stools soft, avoid pushing too hard when going to the toilet, and don't spend longer than you need sitting there.
What the AGA update recommends first
The AGA's Clinical Practice Update, published in Clinical Gastroenterology and Hepatology, is an expert review — a set of Best Practice Advice statements distilled from the available evidence and clinical experience. Its starting point matches the NHS self-care advice: dietary and lifestyle modification — increasing fibre and avoiding straining or prolonged time on the toilet — are reasonable first-line therapies for symptomatic hemorrhoids. (Qureshi et al., Clin Gastroenterol Hepatol, 2026)
On the things many people reach for, the update is honest about how thin the evidence is. Topical treatments — anaesthetics, witch hazel, corticosteroids, vasoactive agents — may be considered, but the efficacy data is limited, and topical steroids should not be used for more than two weeks. Sitz baths (sitting in warm water) are often advised, though, again, the scientific data behind them is limited. None of that means these things can't help; it means the evidence is weaker than their popularity suggests. (Qureshi et al., 2026)
Not every anal symptom is a hemorrhoid
This is the part most worth carrying away. The update points out that the symptoms people pin on "piles" don't always come from hemorrhoids at all. Sharp pain on defecation is most likely an anal fissure — a small tear — rather than a hemorrhoid. And hemorrhoids themselves only cause significant pain when they are acutely thrombosed, meaning a clot has formed. A different cause means a different treatment, which is one reason self-diagnosis can send people down the wrong path. (Qureshi et al., 2026)
When procedures and surgery come in
For hemorrhoids that don't settle with conservative measures, the update sets out a clear ladder, with less invasive options first. Office-based procedures — rubber band ligation or infrared coagulation — are recommended for grade 1 to 3 hemorrhoids before considering surgery. Grade 4 internal hemorrhoids require surgical hemorrhoidectomy. And an acutely thrombosed hemorrhoid is best treated with incision and drainage. The grading simply reflects how much a hemorrhoid prolapses (comes down through the anus); your clinician is the one who assesses it. (Qureshi et al., 2026)
The symptom not to assume away
If there is one message in all of this that matters most for our community, it is about bleeding. It is easy — and common — to see blood and conclude "it's just piles." But NHS guidance on rectal bleeding is clear that a GP will check what is causing it. A small, one-off bleed is usually not a serious problem. But bleeding from the bottom is sometimes a sign of bowel cancer — which is far easier to treat when it is found early — so it is important to get it checked. A lot of blood, or large blood clots, warrants urgent care.
For people living with IBD or an ostomy, this matters doubly: rectal bleeding can have several explanations, and the safe move is never to assume. Knowing your own baseline, and flagging a change, is part of staying ahead of your care rather than behind it.
What this means in practice
The reassuring half of this story is real: most hemorrhoids respond to simple, low-cost measures — more fibre, more fluid, less straining, less time on the toilet — and the AGA update endorses exactly those as first-line. The cautious half is just as real: anal symptoms are not all hemorrhoids, the evidence for some popular remedies is thin, and bleeding deserves a proper look rather than a guess.
Your clinician knows your case best — ask them first.