2025 New Edition ABSITE Sample Question

Answer and Explanation

Did you get it right? The correct answer is D.

Patients with a combination of internal and external hemorrhoids that are symptomatic should generally undergo excisional hemorrhoidectomy.

The management of hemorrhoids varies from conservative to surgical. Treatments are classified into 3 categories:

1. Medical and dietary/lifestyle modifications
2. Office procedures
3. Operative hemorrhoidectomy

All patients with grade 1 or 2 hemorrhoids and most with grade 3 internal hemorrhoids should be treated initially with medical and dietary/lifestyle modifications to correct their constipation. Lifestyle modifications include increasing fiber supplementation and water intake. Patients commonly present currently taking over-the-counter hemorrhoid topical ointments. However, there is no evidence that these products improve symptoms or address the underlying disease pathology.

If these initial measures fail, a number of nonoperative therapies are available. Currently recommended options include rubber band ligation, infrared photocoagulation, and sclerotherapy. Rubber band ligation, infrared photocoagulation, and sclerotherapy will address internal hemorrhoids, but only excisional hemorrhoidectomy will address both internal and external hemorrhoids, particularly in this patient with concurrent grade 3 internal hemorrhoids. Excisional hemorrhoidectomy is the gold standard for the definitive management of hemorrhoids. Complications include urinary retention (most common), postoperative bleeding, stenosis, perineal sepsis, and fecal incontinence if the sphincter muscle is injured.

Grades of Internal Hemorrhoids
Grade	Description	Treatment	Illustration
1	Vascular engorgement and bulging without prolapse	First line: Medical Second line: Office procedures (eg, band ligation)
2	Prolapse with straining but reduces spontaneously	First line: Medical Second line: Office procedures
3	Prolapse reducible with manual pressure	First line: Medical Second line: Office procedures
4	Grossly evident prolapse that is not reducible	Surgical resection
Concurrent internal / external	Hemorrhoids above and below the dentate line	Surgical resection regardless of internal grade

Alternative operative interventions include the stapled hemorrhoidopexy, where an EEA™ circular stapler excises a circumferential ring of hemorrhoidal tissue above the dentate line, excising the internal hemorrhoids and pulling up the external hemorrhoids and fixating them into place. In a transanal hemorrhoid dearterialization, a specialized anoscope with a Doppler is used to identify the feeding arteries to a hemorrhoidal column, which are then suture ligated. These procedures may be less painful than a traditional hemorrhoidectomy; however, there is limited data to support them over traditional resection.

Incorrect Answer Explanations

Answer A: Rubber band ligation is currently the most common method in use for the outpatient treatment of hemorrhoids. Complications of hemorrhoid banding include bleeding, pain, thrombosis, and life-threatening perineal sepsis. However, this will not address external hemorrhoids. External hemorrhoids should not be banded as they are below the dentate line and would cause the patient significant pain.

Answer B: Sclerotherapy involves an injection of a sclerosing agent into the hemorrhoids, resulting in scarring and fibrosis. Side effects include bleeding, pain, ulceration, and sloughing of the mucosa with a risk of abscess or perineal sepsis. Again, this will not address external hemorrhoids and would be extremely painful if applied to external hemorrhoids.

Answer C: The infrared coagulator was designed to decrease blood flow to the region and is less effective in treating large amounts of prolapsing tissue. It is most beneficial in grade 1 and small grade 2 hemorrhoids. It is slightly less painful than rubber banding. This technique is especially useful in patients who fail banding secondary to pain or have symptomatic internal hemorrhoids that are too small to band. External hemorrhoids should not be addressed with infrared coagulation due to the pain and thermal spread.

Answer E: While a transanal hemorrhoid dearterialization may result in less pain than a hemorrhoidectomy, there is a lack of good data to support this procedure over the traditional excisional hemorrhoidectomy, which is the gold standard for the treatment of symptomatic mixed internal and external hemorrhoids.

Bottom Line

For mixed (external and internal) hemorrhoids, excisional hemorrhoidectomy is the treatment of choice to address both components.