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Thrombosed external hemorrhoids
Urgent presentation (<~3 days since onset) Most pts presenting urgently benefit from excision [SR/L] - Exam:1 usually tender blue lump @ anal verge
- Tx: thrombosed ext hemorrhoids eventually self-resolve, yet excision gives more rapid sx resolution, ↓recurrence, longer remission
- Most excisions safely performed in office/ED w/ local anesthetic injection. Excise thrombosis w/ overlying skin to leave wide-open wound (vs simple I&D that allows local recurrence).
Footnotes 1 Exam: viz inspect anus @ rest/straining, digital exam. Dx hemorrhoids by hx, exam. Lab tests almost never helpful. No additional w/u or classification required for thrombosed external hemorrhoids. If there is bleeding, source often requires confirmation by endoscopic studies [SR/M]. Hemorrhoid-pattern bleeding (painless bleed w/ BM) mandates at least sig to r/o other bleed source. If ≥50 yo or if suggestive FHx, may be occasion for entire colon eval, usually by colonoscopy.
Nonurgent presentation (>~3 days since onset) If seen late w/ sx improving and clot already resorbing, may be allowed to resolve w/o excision - Exam:2 usually tender blue lump @ anal verge
- Thrombosed ext hemorrhoids eventually self-resolve
Footnotes 2 Exam: viz inspect anus @ rest/straining, digital exam. Dx hemorrhoids by hx, exam. Lab tests almost never helpful. No additional w/u or classification required for thrombosed external hemorrhoids. If there is bleeding, source often requires confirmation by endoscopic studies [SR/M]. Hemorrhoid-pattern bleeding (painless bleed w/ BM) mandates at least sig to r/o other bleed source. If ≥50 yo or if suggestive FHx, may be occasion for entire colon eval, usually by colonoscopy.
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1st-degree (nonprolapsing) or 2nd-degree (self-reducing prolapsing) or nonlarge 3rd-degree (protruding, requiring manual reduction) Initial tx for symptomatic internal hemorrhoids:3 - 1st-line: ↑ fiber intake + adequate fluids [SR/M]4
- Limit time on toilet, avoid straining
- Topical tx: OTC astringents4/anti-inflammatories of unclear value but commonly used by pts.
If symptomatic despite dietary modifications, refer for office procedure: - Options:5 band ligation probably most effective [SR/M] and popular; sclero; infrared coag. Office procedures may require repeats.
- If large symptomatic ext tags: refer for surgery instead of office procedure [SR/M].
- Avoid in pts w/ thrombocytopoenia or on warfarin/heparin/antiplatelet (eg, clopidogrel), d/t bleed risk.
- If refractory/intolerant to office procedure: refer for surgery [SR/M].
Footnotes 3 Exam: viz inspect anus @ rest/straining, digital exam. Dx hemorrhoids by hx, exam. Lab tests almost never helpful. If there is bleeding, source often requires confirmation by endoscopic studies [SR/M]. Hemorrhoid-pattern bleeding (painless bleed w/ BM) mandates at least sig to r/o other bleed source. If ≥50 yo or if suggestive FHx, may be occasion for entire colon eval, usually by colonoscopy.
4 Cochrane review showed fiber’s benefit on prolapse, bleeding. Laxatives have limited role in initial tx. Astringent enema for sx relief has intuitive appeal.
5 Band ligation via rigid anoscope or retroflexed endoscope w/ ligation attachment. Ligation is reasonable 1st-line for 3rd-degree. Ligation is probably tx of choice for 2nd-degree. Suction-positioning less pain/bleed than forceps, yet both acceptable. Complications: pain, bleeding, thrombosis of ext hemorrhoids, vasovagal sx; life-threatening septic complications vanishingly rare. Infrared coag and sclero can tx bleeding hemorrhoids too small to ligate.
Large 3rd-degree (protruding, requiring manual reduction) or 4th-degree (nonreducible protrusion) If symptomatic,6 refer for surgery [SR/M] - Options:7 hemorrhoidectomy, stapled hemorrhoidopexy, Doppler-assisted hemorrhoidal artery ligation.8
- Surgery may involve various devices, none shows clear advantage.
Footnotes 6 Exam: viz inspect anus @ rest/straining, digital exam. Dx hemorrhoids by hx, exam. Lab tests almost never helpful. If there is bleeding, source often requires confirmation by endoscopic studies [SR/M]. Hemorrhoid-pattern bleeding (painless bleed w/ BM) mandates at least sig to r/o other bleed source. If ≥50 yo or if suggestive FHx, may be occasion for entire colon eval, usually by colonoscopy.
7 Traditional hemorrhoidectomy is very effective. Stapled hemorrhoidopexy is an established alternative in most cases: highly effective for prolapsing internal hemorrhoids, yet may not adequately address ext hemorrhoids.
8 Doppler-assisted hemorrhoidal artery ligation success rates comparable to hemorrhoidectomy/stapled hemorrhoidopexy, but no comparative studies yet.
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