eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Thrombosed External Hemorrhoid Excision

Author: Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Coauthor(s): Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Contributor Information and Disclosures

Updated: Apr 30, 2009

Introduction

External hemorrhoids occur distal to the dentate line and develop as a result of distention and swelling of the external hemorrhoidal venous system. Engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid (TEH), a bluish-purplish discoloration often accompanied by severe incapacitating pain. Although TEH is a common problem, it remains a poorly studied topic. Reported risk factors for TEH include a recent bout of constipation1,2 and traumatic vaginal delivery.3,4

Physicians: Peer Review this Article on Medscape Physician Connect.

Thrombosed hemorrhoid. Image courtesy of Dr. Jona...

Thrombosed hemorrhoid. Image courtesy of Dr. Jonathan Adler. This thrombosed hemorrhoid was treated by incision and removal of clot.

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Thrombosed hemorrhoid. Image courtesy of Dr. Jona...

Thrombosed hemorrhoid. Image courtesy of Dr. Jonathan Adler. This thrombosed hemorrhoid was treated by incision and removal of clot.


Anatomy of external hemorrhoid. Image courtesy of...

Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.

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Anatomy of external hemorrhoid. Image courtesy of...

Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.


Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) ultimately result in resolution of symptoms for most patients, surgical excision of the TEH may often be the best treatment.5,6 In one retrospective study,7 surgical treatment resulted in much faster symptom resolution (3.9 d vs 24 d) as well as lower frequency of recurrence (6.3% vs 25.4%) in the study population. Another study8 demonstrated that, compared with simple incision or topically applied 0.2% glycerin trinitrate ointment, TEH excision improved recurrence rates, symptoms, and residual skin tags at 1-year follow-up.9

Newer conservative treatments such as topical nifedipine show promise over traditional conservative treatments such as lidocaine ointment;10 however, they have not yet been shown to decrease time to symptom resolution or frequency of recurrence as compared to surgical excision.

Surgical excision of the acutely thrombosed external hemorrhoid is within the purview of an office-based or emergency practitioner.

Indications

Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision.

Contraindications

Absolute contraindications to thrombosed external hemorrhoid excision in the emergency department include the following:

  • Any concern that the lesion may not be a thrombosed external hemorrhoid (including a painless rectal mass, since thrombosed external hemorrhoids are painful)
  • Grade IV internal hemorrhoid associated with a thrombosed external hemorrhoid
  • Known severe coagulopathy
  • Hemodynamic instability
Relative contraindications to emergency department excision of thrombosed external hemorrhoid include the following:

More on Thrombosed External Hemorrhoid Excision

Overview: Thrombosed External Hemorrhoid Excision
Treatment & Medication: Thrombosed External Hemorrhoid Excision
Multimedia: Thrombosed External Hemorrhoid Excision
References
Further Reading
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References

  1. Oh C. Acute thrombosed external hemorrhoids. Mt Sinai J Med. Jan 1989;56(1):30-2. [Medline].

  2. Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating fact from fiction. World J Gastroenterol. Aug 21 2007;13(31):4161-7. [Medline].

  3. Abramowitz L, Sobhani I, Benifla JL, Vuagnat A, Daraï E, Mignon M, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum. May 2002;45(5):650-5. [Medline].

  4. Cheng CY, Li Q. Integrative review of research on general health status and prevalence of common physical health conditions of women after childbirth. Womens Health Issues. Jul-Aug 2008;18(4):267-80. [Medline].

  5. Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg. Feb 2007;16(1):71-8. [Medline].

  6. Alonso-Coello P, Mills E, Heels-Ansdell D, López-Yarto M, Zhou Q, Johanson JF, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. Jan 2006;101(1):181-8. [Medline].

  7. Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum. Sep 2004;47(9):1493-8. [Medline].

  8. Cavcic J, Turcic J, Martinac P, Mestrovic T, Mladina R, Pezerovic-Panijan R. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis. May 2001;33(4):335-40. [Medline].

  9. Tan KY, Sng KK, Tay KH, Lai JH, Eu KW. Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy. Br J Surg. Dec 2006;93(12):1464-8. [Medline].

  10. Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. Mar 2001;44(3):405-9. [Medline].

  11. Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician. Apr 15 2002;65(8):1629-32, 1635-6, 1639. [Medline]. [Full Text].

  12. Feldman M. Hemorrhoids. In: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 7th ed. Elsevier; 2002:2281-82.

  13. Reichman EF, Simon RR. External Hemorrhoid Management. In: Emergency Medicine Procedures. McGraw-Hill Medical Publishing; 2004:496-500.

  14. Roberts JR, Hedges JR. Anorectal Procedures. In: Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, PA: WB Saunders Company; 2004:871-4.

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Further Reading

National Institute of Diabetes and Digestive and Kidney Disease, NIH: Hemorrhoids

National Library of Medicine, NIH: Hemorrhoids

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Keywords

hemorrhoid, thrombosed external hemorrhoid, hemorrhoid excision, hemroid, hemroids, hemorrhoid treatment, hemorrhoid surgery, external hemorrhoid, external hemorrhoids, hemorrhoid relief, thrombosed hemorrhoid, hemorrhoid pictures

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Contributor Information and Disclosures

Author

Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Brett Wallace Lorber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

 
 
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