Thrombosed Hemorrhoids
You should be familiar with these painful offenders because half to two-thirds of people between 45 and 65 will suffer from their cruelty - James R. Roberts MD and Martha Roberts PNP
HWN Suggests
Everything you wanted to know about hemorrhoids and anal fissures, but were afraid to ask
One of the questions that emergency physicians face frequently is whether an external hemorrhoid should be incised or not. According to Dr. Cavanaugh, many so-called thrombosed hemorrhoids are actually acute flares that do not require surgical intervention. If the overlying skin is not taught and purple and a hard mass cannot be palpated inside, incision is likely to cause more pain and discomfort than the patient already has. Moreover, if symptoms have been present for more than 2-3 days, the chances of retrieving a clot are greatly diminished and conservative management with warm baths and a prescription steroid cream is more prudent. In these cases, it will often take a few weeks for the…
Articles of Interest
Thrombosed External Hemorrhoids
Thrombosis of external hemorrhoids occurs with an unknown cause, and follows an abrupt onset of anal mass and pain within 48 h. The pain diminishes after the fourth day and if left alone dissolves spontaneously in a few weeks. The treatment should consist of pain relief, prevention of recurrent thromboses, and residual skin tags. The thrombus is excised with local or general anesthesia. Greenspon et al. detected on a case series of 231 patients with thrombosed hemorrhoids that with conservative treatment, symptoms resolved in 24 days and with surgery in 4 days. The recurrence rate was 25 % in the conservative group and 6 % in the surgery group.
Thrombosed Hemorrhoids
Thrombosed external hemorrhoids that are not drained most likely will spontaneously rupture in one to three weeks and leave a skin tag behind. Sitz baths two to three times a day are often curative if a patient declines drainage in the ED.
Hemorrhoids and Anal Fissures
Conservative treatment (sitz baths and bulk laxatives) IF: Thrombosis >72hrs. Swelling starting to shrink. Pain is tolerable. Conservative treatment can include topical 0.3% nifedipine and 1.5% viscous lidocaine. Consider excision IF: Patient is not immunocompromised, child, pregnant, portal hypertension, or coagulopathic. Thrombosis <72 hours (acute). Extremely Painful.
Hemorrhoids: Diagnosis and Treatment Options
Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.
The acute management of haemorrhoids
If seen within the first 24–48 hours, evacuation of the clot under local anaesthesia is recommended. Care should be taken to remove all of the visible clot. It is not necessary to pack the cavity. A circumferential rather than a radial incision may help prevent a skin tag forming after healing.
The Bottom Line: Hemorrhoids and Anal Fissures in the ED
Instead of incision and expression of clot for thrombosed external hemorrhoids, consider in-house surgical referral for excision.
