Emergency Notes

Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset.

In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable.

Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis.

Excision of thromboses

Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.

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:

• Allergy to local anesthetic
• Perianal infection
• Anorectal fissure
• Portal hypertension
• Inflammatory bowel disease
• Known coagulopathy
• Any serious systemic illness or comorbidity that would significantly increase the risk of the procedure

Acute hemorrhoidal crisis


Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is a large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

Technique


Tape bottom T

Apply an ice pack for 15 minutes

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


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

Dress the wound with 4 × 4 gauze pads folded over once and taped into place in a transverse fashion

Postcare

After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by warm baths 2-3 times daily, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check.


Patient should start sitz baths as soon as possible. Sitz baths should be taken 3-4 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

 

Conservative tx

✓ If topical mucosal anesthetic does not give enough relief to permit examination, follow with subcutaneous injection of 5 to 10 mL of 1% lidocaine with epinephrine or bupivacaine 0.5% with epinephrine for extended pain relief.

✓ If topical anesthetics on the rectal mucosa help control the pain, provide for more of the same, perhaps also with some added corticosteroid for anti-infl ammatory eff ect (Anusol-HC cream).

✓ Pain may also be relieved by reducing sphincter spasm. Prescribe topical nifedipine 0.3% or diltiazem gel 2% with lidocaine gel 1.5% to be applied every 12 hours. Topical glyceryl trinitrate 0.2% or nitroglycerin ointment can be substituted for the diltiazem and nifedipine, but many patients are unable to tolerate the headaches that frequently occur.

 

http://emedicine.medscape.com/article/81039-overview#aw2aab6b4