Richard E. Burney
Presentation
A 49-year-old obese male presents to the emergency department with a complaint of severe anal pain for the past 24 hours. He has not had this problem before. Over-the-counter pain medication has not helped. He has a history of constipation and recently returned from a business trip. Past medical history includes type 2 diabetes, hypertension, hyperlipidemia. He reports being compliant with medications prescribed for these conditions, including an oral hypoglycemic agent, aspirin, a statin agent, and a beta-blocker. On examination, he is afebrile. He has an exquisitely tender, swollen, edematous mass at the anal verge, with bluish discoloration, about 1.5 to 2 cm in diameter. There is no apparent cellulitis or erythema. He does not allow digital rectal examination.
Differential Diagnosis
The most likely diagnosis in this man is an acutely thrombosed external hemorrhoid (Figure 1). Other possibilities in decreasing order of probability include (1) prolapsed edematous internal hemorrhoid (Figures 3-5); (2) acute hemorrhoidal inflammation and edema brought on by constipation (Figure 2); (3) perianal abscess; (4) prolapsed, strangulated internal hemorrhoid; (5) inflamed anal tag with or without associated inflammatory bowel disease; (6) infarcted hemorrhoid without prolapse; (7) prolapsed anal polyp; and (8) acute anal fissure, with an edematous sentinel tag.
FIGURE 1 • Thrombosed external hemorrhoid: characteristic appearance.
FIGURE 2 • Acutely inflamed hemorrhoid with thrombosis and ulceration. This was treated by hemorrhoidectomy in the operating room.
FIGURE 3 • Chronically prolapsed mixed internal/external hemorrhoid. Bluish discoloration in places suggests underlying thromboses, but do NOT try to I&D this.
FIGURE 4 and 5 • Chronically prolapsed left lateral internal hemorrhoid. This is NOT a thrombosed external hemorrhoid. It was manually reduced under local anesthesia.
Workup
Additional questions regarding patient’s normal bowel habit, management of his chronic constipation, and medications are warranted. It is important to determine if he regularly strains when moving his bowels. The diagnosis is almost always made on the basis of physical examination. To do a good examination, the patient is best placed in prone jackknife position on a sigmoidoscopy table and examined under good light with the buttock spread apart. If a sigmoidoscopy table is not available, the patient can be placed in prone, jackknife position by lying face-down over rolled blankets placed under the hips to elevate the buttocks. Laboratory and imaging studies are rarely helpful unless the patient has a fever or at the time of examination, anal abscess is a distinct possibility. On rare occasion, examination may have to be facilitated by sedation or local anesthetic injection or evaluation under spinal or general anesthesia done in the operating room.
Diagnosis and Treatment
The diagnosis in this patient, based on history and physical examination, is thrombosed external hemorrhoid. This condition, although painful, is selflimited. Although surgical treatment, consisting of incision and evacuation of clots, is possible, it is not required. This is particularly true if the thrombosis is more than 48 to 72 hours old, by which time the acute inflammation and swelling are beginning to abate. With observation and attention to a proper diet, the hemorrhoidal thrombosis will reabsorb and the swelling will subside, leaving no sequelae. There is a common misconception that thrombosed hemorrhoids are an indication that there is some kind of underlying hemorrhoidal or other disease. This is not true.
Surgical Approach
If the acute thrombosis is <48 hours old and/or is quite large, such that one can anticipate it will take weeks for the swelling to subside, surgical treatment may be offered. The simplest and most efficacious, as well as expedient, surgical treatment is incision and evacuation of clot (Figures 6-8).
FIGURE 6-8 • Incision and drainage of thrombosed external hemorrhoid. Note that ellipse of skin has been excised over the thrombosis giving good exposure. After thrombectomy, there is still residual swelling. No sutures are required.
This procedure can be done under local anesthesia in the office, clinic, or emergency department. 1% lidocaine with epinephrine is infiltrated through a very fine needle slowly into the dermis overlying the hemorrhoid. Infiltrating the subcutaneous tissue is not effective. The skin will blanch as this is done. It is not usually necessary to do a deeper block. After the local anesthetic has taken effect, an ellipse of skin is excised over the area of thrombosis, oriented to give the best exposure to the underlying thrombus. Simple, linear incision does not provide adequate exposure. The thrombi are intravascular, in small hemorrhoidal veins, and there are usually three to six vessels present containing thrombi. Thrombi are evacuated with a fine hemostat. The skin incision is left open. A longer-acting local anesthetic agent such as bupivacaine may be infiltrated as well. Postoperative care consists of an outer dressing to absorb any drainage, sitz baths or moist applications, and nonsteroidal pain medications. Antibiotics are not needed.
The chief potential pitfall is failure to make the correct diagnosis. Prolapsed, thrombosed, or strangulated internal hemorrhoids have been mistaken for thrombosed external hemorrhoids, leading to painful errors in management (Figures 2-4). Thrombosed (external) hemorrhoids are covered with dry, keratinized normal-appearing skin (Figure 1). If this is not observed, consider another diagnosis. Other potential pitfalls are failure to have adequate lighting, assistance, and exposure, which will make the procedure more difficult. Other common pitfalls include the following: failure to adequately anesthetize the skin overlying the thrombosed hemorrhoid, or to wait long enough for the local anesthetic to be effective (at least 2 minutes); failure to make an elliptical or a lanceolate incision that exposes all the thrombosed veins; and failure to carefully evacuate thrombus from each vein individually (Table 1).
TABLE 1. Key Technical Steps and Potential Pitfalls of Incision and Evacuation of Hemorrhoidal Thrombi
Special Intraoperative Considerations
If you find after gaining good exposure and lighting that you are not dealing with a thrombosed external hemorrhoid, but rather with prolapsed, strangulated internal hemorrhoids or other condition, (Figure 2)the patient may need to be evaluated in the operating room under better anesthesia, such as subarachnoid block.
Postoperative Management
No special postoperative management is needed. The patient may keep a slightly moistened gauze dressing over the operative site, which usually closes within a day or two. It will, however, be painful when the local anesthetic wears off and remain so for several days. It is a good idea to explain this to the patient. Stool softener and instructions for high-fiber diet should be given. There is no reason to subject the patient to additional examinations, such as colonoscopy. Thrombosed external hemorrhoids are rarely associated with underlying pathology of any kind, including internal hemorrhoids.
TAKE HOME POINTS
· First, be sure you have the right diagnosis. Remember that not all thrombosed hemorrhoids need surgical treatment; the majority of patients do not.
· Treatment does not lead to rapid resolution of symptoms, especially if the thrombosis is more than 72 hours old.
· If you do decide to evacuate thrombi, have adequate positioning, light, and assistance. Infiltrate local anesthetic slowly but widely into the skin. Take an ellipse of overlying skin and extract all the thrombi individually.
· Explain to the patient that there will be continued pain and swelling for several days or longer despite what you have done.