Educational draft · awaiting clinical reviewUse Rapid for revision, not patient-care decisions. Check current national and local guidance and the BNF or BNFC before acting.
2 min synopsisUK scopeSources checked 8 Sept 2026Clinical review pending
Saved on this device
!
Major bleeding or severe pain after treatment
Collapse with rectal bleeding, compromised prolapsed tissue or fever with severe pain and urinary difficulty after banding requires immediate assessment.
Action: Assess circulation and bleeding, obtain urgent senior colorectal help and resuscitate as indicated; suspected post-banding sepsis needs immediate antimicrobial treatment and examination under anaesthesia.
Synopsis
Distinguish symptomatic haemorrhoidal cushions from other causes of bleeding and prolapse, and select investigation, bowel treatment and an appropriate office or surgical procedure.
Internal haemorrhoids usually cause painless bright red bleeding or discrete prolapsing cushions; severe pain suggests thrombosis, strangulation, fissure or another diagnosis.
Investigate concerning bleeding even when haemorrhoids are visible; a rectal or unexplained anal mass or ulcer does not require FIT before referral is considered.
Start with assessed bowel habit, adequate fibre and fluid, less straining and shorter toilet visits; confirm unexplained bleeding before prescribing the selected ispaghula product.
Key red flags
Persistent bleeding with weight loss, altered bowel habit or iron-deficiency anaemia must retain a colorectal cancer differential.
A rectal mass or unexplained anal mass or ulceration warrants the appropriate suspected cancer referral without waiting for FIT.
Escalating anal pain, fever and difficulty passing urine after rubber-band treatment can indicate deep infection rather than expected discomfort.
Investigation priorities
01
Full blood count with indicated iron studiesFirst step
Assess the physiological consequences of recurrent or substantial blood loss.
Management branches
Worked caseResolve persistent grade II symptoms
A 42-year-old woman reports six months of painless bleeding and spontaneously reducing tissue.
Examination and anoscopy show grade II internal cushions without an anal mass or fissure. The colorectal assessment includes her persistent bleeding and bowel history; completed lower gastrointestinal evaluation finds no other source. Haemoglobin is normal. She has no dysphagia, obstruction, unexplained new bowel change, relevant drug interaction or anticoagulant use, and the bleeding is attributed to the examined cushions.
She starts the selected Fybogel Orange 3.5 g sachet in 150 mL water morning and evening after meals, separated from other medicines, together with less straining and shorter toilet visits. At six weeks her stool is soft but bleeding still disrupts work. After consent, rubber bands are placed above the dentate line on the symptomatic internal cushions; immediate severe pain is absent and she receives bleeding, fever and urinary-retention return advice.
Key medicines
Fybogel Orange ispaghula husk 3.5 g sachetFor an adult whose bleeding has been assessed and attributed to haemorrhoids, take one sachet orally morning and evening, preferably after meals, freshly mixed into at least 150 mL water. Separate it from other medicines by at least half to one hour and do not take immediately before sleep. Seek review if constipation persists or no bowel movement occurs after three days.Do not use for undiagnosed rectal bleeding, a sudden bowel-habit change persisting over two weeks, failure to defaecate after a laxative, faecal impaction, obstruction or gastrointestinal narrowing, reduced gut motility, oesophageal disease or swallowing/throat difficulty. Never take dry. Avoid concurrent opioids or other motility inhibitors except under medical supervision. Review renal potassium restriction, phenylketonuria because of aspartame, and allergy to ispaghula or excipients. Diabetes and thyroid-hormone treatment need supervision; absorption of lithium, carbamazepine, anticoagulants and other medicines can be delayed. Pregnancy or breastfeeding use may be considered if dietary change is insufficient. Stop for abdominal pain, choking or hypersensitivity and seek assessment.
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 8 Sept 2026; clinical approval remains outstanding.
ASCRS haemorrhoids guideline 2024Haemorrhoids and prolapse: Haemorrhoids and prolapse scope: May 2024; DOI 10.1097/DCR.0000000000003276; actual clinical recommendations read 8 September 2026.
NICE NG12 suspected cancer recognition and referralHaemorrhoids and prolapse: Haemorrhoids and prolapse scope: Current colorectal and anal recommendations 1.3.1–1.3.6 read 8 September 2026; distinguish FIT triage from direct mass/ulcer referral.
Fybogel Orange selected UK SmPCHaemorrhoids and prolapse: Haemorrhoids and prolapse scope: Ispaghula 3.5 g sachet; actual sections 4.1–4.6 read 8 September 2026.