Thrombosed External Hemorrhoid Excision 

Updated: Apr 08, 2020
Author: Brett Wallace Lorber, MD, MPH, FACEP; Chief Editor: Erik D Schraga, MD 

Overview

Background

External hemorrhoids (piles) occur distal to the dentate line and develop as a result of distention and swelling of the external hemorrhoidal venous system (see the first image below).[1] Engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid, a bluish-purplish discoloration often accompanied by severe incapacitating pain (see the second image below).

Anatomy of external hemorrhoid. Image courtesy of Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.
Thrombosed hemorrhoid, treated with incision and r Thrombosed hemorrhoid, treated with incision and removal of clot. Image courtesy of Dr. Jonathan Adler.

Thrombosed external hemorrhoids are a common problem but remain a poorly studied topic. Reported risk factors for thrombosed external hemorrhoid include a recent bout of constipation[2, 3] and traumatic vaginal delivery.[4, 5]

Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) ultimately results in improvement of symptoms for most patients, surgical excision of the thrombosed external hemorrhoid often precipitates resolution.[6, 7, 8]

Newer conservative treatments, such as topical nifedipine, show promise of having advantages over traditional conservative treatments, such as lidocaine ointment[9] ; however, in comparison with surgical excision, they have not yet been shown to shorten the time to symptom resolution or reduce the frequency of recurrence.

Surgical excision of the acutely thrombosed external hemorrhoid is within the purview of an office-based or emergency practitioner.[10, 11] This safe procedure offers low recurrence and complication rates and high levels of patient acceptance and satisfaction.[12]

Go to Hemorrhoids and Anal Surgery for Hemorrhoids for complete information on these topics.

Indications

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

In a retrospective study by Greenspon et al, surgical treatment resulted in much faster symptom resolution (3.9 days vs 24 days), as well as a lower frequency of recurrence (6.3% vs 25.4%), in the study population.[13] A study by Cavcić et al demonstrated that in comparison with simple incision or topically applied 0.2% glycerin trinitrate ointment, thrombosed external hemorrhoid excision improved recurrence rates, symptoms, and residual skin tags at 1-year follow-up.[14]

Contraindications

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

  • Any concern that the lesion may be something other than a thrombosed external hemorrhoid, such as a painless rectal mass (thrombosed external hemorrhoids are always painful)
  • A grade IV internal hemorrhoid associated with a thrombosed external hemorrhoid
  • Known severe coagulopathy
  • Hemodynamic instability

Relative contraindications to ED excision of a thrombosed external hemorrhoid include the following:

 

Periprocedural Care

Patient Education and Consent

Explain the procedure, benefits, risks, complications, and alternatives to the patient, the patient’s representative, or both. Obtain a signed informed consent. Ask the patient or the patient’s representative if he or she would like others to be present for the procedure.

Equipment

Equipment required for the procedure includes the following:

  • Direct dedicated lighting
  • Sterile gloves
  • Antiseptic solution with skin swabs
  • Sterile drape
  • Local anesthetic solution (0.5% bupivacaine or 1% lidocaine with epinephrine)
  • Syringe, 5 mL
  • Needles, 18-gauge and 25- or 27-gauge
  • Small forceps for grasping tissue
  • Iris scissors to cut tissue or packing gauze
  • Scalpel blade on a handle, No. 11 or No. 15
  • Multiple gauze squares, 4- × 4-in.
  • Adhesive tape, 2-in.
  • Absorbable suture, 3-0
  • Sterile packing gauze, 0.25-in.
  • Sterile dressing

It is important to have the equipment required for rescue techniques (eg, suturing equipment, silver nitrate) available at the bedside, in case bleeding occurs that is not controlled by direct pressure.

Patient Preparation

Anesthesia

Pain control is extremely important for excision of a thrombosed external hemorrhoid. Assurance of adequate local anesthesia is important; at times, procedural sedation may be warranted. Local anesthesia for this procedure is discussed further below (see Technique). For more information, see Local Anesthetic Agents, Infiltrative Administration.

Positioning

Place the patient in the prone or lateral decubitus position, with the gurney at a height that accommodates the practitioner. Position the patient prone on the gurney, and use two overlapping sheets to cover the patient’s buttocks. One sheet extends down the legs, and the other extends up the back.

Monitoring and Follow-up

Return precautions should be given both verbally and in written form. They should include the following:

  • Uncontrolled pain
  • Signs of infection (eg, pus, redness, fever)
  • Moderate-to-severe bleeding (minor bleeding is extremely common)

A wound check is necessary if pain or bleeding persists for more than 36-48 hours postoperatively.

 

Technique

Excision of Thrombosed External Hemorrhoid

To increase exposure to the area, tape each buttock in a T pattern. First, place two long strips of tape (~40 cm long) longitudinally on each buttock. These strips should extend from the lower back down to the upper thigh. Next, place another long strip of tape horizontally across the two vertically oriented strips. Pull the horizontal strips out to the side, and tape them to the gurney. (See the image below.)

Excision of thrombosed external hemorrhoid. Taping Excision of thrombosed external hemorrhoid. Taping of patient before procedure (thrombosed external hemorrhoid is at 9-o'clock position).

Prepare a light source for the sterile field (see the image below). Use direct lighting; do not rely on ambient light alone.

Excision of thrombosed external hemorrhoid. Prepar Excision of thrombosed external hemorrhoid. Preparation of light source for sterile field.

After cleaning the area with an alcohol swab, locally inject approximately 2-6 mL of local anesthetic (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, then inject approximately 1-2 mL of the local anesthetic within the hemorrhoid (see the video below).

Excision of thrombosed external hemorrhoid. Injection of local anesthetic at hemorrhoid base and within hemorrhoid.

Use skin swabs and antiseptic solution to clean the skin, starting at the hemorrhoid and working outward in progressively larger circles (see the video below). Next, create a sterile field with sterile drapes surrounding the projected work area.

Excision of thrombosed external hemorrhoid. Application of povidone-iodine antiseptic.

Make an elliptical incision in the roof of the hemorrhoid, taking care to avoid the anal sphincter muscle (see the video below). The incision should be directed radially from the anal orifice. The elliptical incision allows the thrombosed hemorrhoid to be unroofed. It is preferable to a simple incision and evacuation of clot because of the usual presence of multiloculated clots and their tendency to close and reclot if not unroofed. The use of an elliptical incision reduces the complication rate.[15]

Excision of thrombosed external hemorrhoid. Primary elliptical incision over hemorrhoid.

Remove the blood clot from the elliptical opening (see the video below). Multiple clots are often present; all clots should be removed.

Excision of thrombosed external hemorrhoid. Further incision with removal of clot.

Use 0.25-in. packing material to pack any space left by the removal of the clot, taking care not to pack tightly (see the video below).

Excision of thrombosed external hemorrhoid. Gauze packing after procedure.

Dress the wound with 4-in. × 4-in. gauze pads folded over once and taped into place in a transverse fashion (see the images below).

Excision of thrombosed external hemorrhoid. Dressi Excision of thrombosed external hemorrhoid. Dressing after excision.
Excision of thrombosed external hemorrhoid. Dressi Excision of thrombosed external hemorrhoid. Dressing after excision.

Postoperative Care

Patient should start sitz baths as soon as possible. Sitz baths should be taken three or four times a day for 20 minutes at a time in warm but not hot water. Packing gauze can be removed in 48 hours if it has not yet fallen out.

Acetaminophen or ibuprofen should be prescribed for pain control. Avoid opiate analgesics because of constipating and, thus, stool-hardening effects. If opiates are felt necessary, stool softeners and/or laxatives must be used in conjunction. Antibiotics are not essential. The patient should remain well hydrated and take a stool softener to avoid traumatic passage of feces. This should be continued for 2-4 weeks.

Complications

The following are potential complications of thrombosed external hemorrhoid excision:

  • Bleeding - Probably the most common complication of this procedure, bleeding can usually be well controlled with direct pressure; if hemostasis is not obtained with direct pressure alone, either silver nitrate cauterization or a figure-eight stitch with an absorbable suture can be used
  • Infection – The infection rate is not known but is believed to be lower than 5%; prophylactic antibiotics are not routinely indicated
  • Perianal skin tag - This is a common benign complication after the incised area has healed
  • Stricture - This is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle
  • Incontinence - This is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle
  • Pain - This is a common but avoidable complication that generally is completely preventable with any combination of parenteral and local anesthesia, with or without procedural sedation
 

Questions & Answers

Overview

Where are external hemorrhoids (piles) located?

What are the risk factors for thrombosed external hemorrhoid?

What are the treatment options for thrombosed external hemorrhoids?

What is the role of excision in the treatment of thrombosed external hemorrhoids?

When is excision indicated in the treatment of external hemorrhoids?

What are the absolute contraindications to emergent excision of thrombosed external hemorrhoids?

What are the relative contraindications to emergent excision of thrombosed external hemorrhoids?

Periprocedural Care

What patient education should be given regarding excision of thrombosed external hemorrhoids?

What equipment is required for thrombosed external hemorrhoid excision?

What type of anesthesia is indicated in thrombosed external hemorrhoid excision?

How should patients be positioned for a thrombosed external hemorrhoid excision?

How should patients be monitored following excision of thrombosed external hemorrhoids?

Technique

How is exposure to thrombosed external hemorrhoid increased prior to excision?

Where is local anesthetic injected for excision of thrombosed external hemorrhoids?

How is a sterile field created for excision for thrombosed external hemorrhoids?

How is an elliptical incision made in thrombosed external hemorrhoid excision?

How should blood clots be removed from thrombosed external hemorrhoids?

How is gauze packed following thrombosed external hemorrhoid excision?

How is the wound dressed following thrombosed external hemorrhoid excision?

What is the postoperative care for thrombosed external hemorrhoid excision?

What are the possible complications of thrombosed external hemorrhoid excision?