Internal Hemorrhoids: A Source of Massive Obscure Lower Gastrointestinal Bleeding in Cirrhosis

Anorectal bleeding is the second most common site of lower gastrointestinal bleeding. Colonoscopy remains the gold standard test to localize sources of lower gastrointestinal bleeding, but it can miss left-sided colon pathologies such as diverticula, rectal varices, and internal hemorrhoids. We report an unusual case of a male cirrhotic patient with massive hemorrhoidal bleeding which went undiagnosed despite multiple imaging and endoscopic evaluations. He underwent urgent sigmoidoscopy that identified grade III internal hemorrhoids and sclerotherapy which resolved the hematochezia. Decompensated cirrhosis complicates patient candidacy for surgical hemorrhoidectomy, but sclerotherapy is a viable option even for high-risk patients. Urgent sigmoidoscopy during active bleeding should be considered if hemorrhoidal bleeding is suspected but inconclusive by colonoscopy.