Thrombosed external hemorrhoid

A thrombosed external hemorrhoid is a localized thrombosis of the inferior hemorrhoidal venous plexus that results in severe, acute anal pain. Perianal clinical examination reveals a bulging, purplish nodule that is very tender to palpation. It may be treated conservatively with analgesic creams and steroids or be surgically excised for immediate pain relief.

External hemorrhoids are located distal to the dentate (pectinate) line; and are drained by the inferior hemorrhoidal (rectal) plexus. External hemorrhoid thrombosis occurs if a clot forms in the inferior hemorrhoidal plexus.

References:^[1]

• Risk factors
  • Constipation
  • Straining during defecation
  • Pregnancy
  • Physical strain: e.g., (new) athletic activities
  • Hemorrhoids

References:^[1]

• Acute distention blood vessels → pooling of the blood → thrombus formation → inflammation and distention of the overlying perianal skin → severe pain

References:^[2]

• Acute onset of severe pain
• Pain with defecation
• May ulcerate and bleed
• Thrombosed hemorrhoid detectable on rectal exam: palpable, bulging, dark red to purplish nodule at the outer rim of the anal canal; very tender to palpation

If the patient also presents with systemic symptoms such as weight loss, night sweats, or abdominal pain, underlying malignancy or infection must be ruled out!

References:^[1]

• Prolapsed and/or strangulated internal hemorrhoids
• Anal fissures, rectal ulcers, proctitis
• Perianal abscesses and fistulas
• Rectal prolapse
• Polyps, rectal cancer

References:^[1]

The differential diagnoses listed here are not exhaustive.

Conservative

• Indications: small thromboses , thromboses older than 72 hours, current pregnancy
• Treatment
  • Analgesic creams (e.g., hydrocortisone/lidocaine)
  • Topical anti-inflammatories (e.g., hydrocortisone cream)
  • Antispasmodic agents (e.g., topical nitroglycerin or nifedipine)
  • Increased intake of fluids and fiber to promote easier passage of stool
  • Warm sitz baths
• Thromboses usually resolve or improve within 2–3 days. Surgery is rarely required.

Surgical

• Indications
  • Thrombosis with acute severe pain within 72 hours of onset → rapid pain relief
  • Symptoms refractory to conservative treatment
  • Combination of both internal and external hemorrhoids
• Treatment
  • Excision of external hemorrhoid
  • Alternatively, incision and evacuation of the thrombus
• Complications (rare): recurrence requiring further surgery, local swelling, minor bleeding, perianal fistula or abscess

References:^[1][3]

1. Mounsey AL, Halladay J, Sadiq TS . Hemorrhoids. Am Fam Physician. 2011; 84 (2): p.204-210.
2. Bleday R, Breen E. Treatment of hemorrhoids. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/treatment-of-hemorrhoids?source=preview&search=%2Fcontents%2Fsearch&anchor=H25#H25.Last updated: July 6, 2015. Accessed: December 5, 2016.
3. Lorber BW. Thrombosed External Hemorrhoid Excision. In: Schraga ED, Thrombosed External Hemorrhoid Excision. New York, NY: WebMD. http://emedicine.medscape.com/article/81039-overview. Updated: September 2, 2016. Accessed: December 12, 2016.
4. Müller M. Chirurgie für Studium und Praxis (2012/13). Medizinische Verlags- und Informationsdienste ; 2011
5. Siewert JR. Chirurgie. Springer Verlag (2006)
6. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders.. Am J Gastroenterol. 2014; 109 (8): p.1141-57; (Quiz) 1058. doi: 10.1038/ajg.2014.190 . | Open in Read by QxMD