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Clinical Procedures > Soft Tissue Procedures
Thrombosed External Hemorrhoid Excision
Article Last Updated: Sep 18, 2008
AUTHOR AND EDITOR INFORMATION
Section 1 of 14  
Author: Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Brett Wallace Lorber is a member of the following medical societies: American College of Emergency Physicians
Coauthor(s):
Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Editors: Andrew K Chang, MD, Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine; 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; 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; Jonathan Adler, MD, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital; Division of Emergency Medicine, Harvard Medical School
Author and Editor Disclosure
Synonyms and related keywords:
hemorrhoid, thrombosed external hemorrhoid, hemorrhoid excision, hemroid, hemroids, hemorrhoid treatment, hemorrhoid surgery, external hemorrhoid, external hemorrhoids, hemorrhoid relief, thrombosed hemorrhoid, hemorrhoid pictures
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
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 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-up9
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 physician.
For a CME activity on hemorrhoids, see the Medscape article Hemorrhoid Management Revisited.
Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision.
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:
- 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 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 4 X 4 gauze squares
- Adhesive tape, 2 inch
- Absorbable suture, 3-0
- Sterile packing gauze, quarter inch
- Sterile dressing
- Position the patient in the prone or lateral decubitus position with the gurney at a height that accommodates the physician.
- 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.
- Position the patient prone on the gurney and use 2 overlapping sheets to cover the patient's buttocks. One sheet extends down the legs and the other extends up the back.
- To increase exposure to the area, tape each buttock in a T pattern. First, place 2 long strips of tape (approximately 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 2 vertically oriented strips. Pull the horizontal strips out to the side and tape them to the gurney.
Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position). - Prepare light source for sterile field.
Light source preparation for sterile field. - After cleaning the area with an alcohol swab, locally inject approximately 2-6 mL of local anesthesia (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, and inject approximately 1-2 mL of the local anesthesia within the hemorrhoid.
Local anesthesia injected at hemorrhoid base and within the hemorrhoid. - Use skin swabs and antiseptic solution to clean the skin. Start at the hemorrhoid and work outward in progressively larger circles. Next, create a sterile field with sterile drapes surrounding the projected work area.
Application of povidone-iodine (Betadine) antiseptic. - Make an elliptical incision in the roof of the hemorrhoid, taking care to avoid the anal sphincter muscle. The incision should be directed radially from the anal orifice. The elliptical incision allows the thrombosed hemorrhoid to be unroofed. It is preferred over a simple incision and evacuation of clot because of the usual presence of multiloculated clots and their tendency to close and re-clot, if not unroofed.
Primary elliptical incision over hemorrhoid. - Remove the blood clot from the elliptical opening. Multiple clots are often present; all clots should be removed.
Further incision with removal of clot. - Use quarter-inch packing material to pack any space left by the removal of the clot. Take care not to pack tightly.
Gauze packing postprocedure. - Dress wound with 4 X 4 gauze pads folded over once and taped into place in a transverse fashion.
Dressing postexcision.
Dressing postexcision.
- Pain control is extremely important for this procedure. Assurance of adequate local anesthesia is important; at times, procedural sedation may be warranted.
- Have rescue techniques (eg, suturing equipment, silver nitrate) at the bedside in case direct pressure does not control the bleeding.
- Use direct lighting. Do not rely on ambient light alone.
- Always make an elliptical incision rather than a simple incision to decrease the rate of complications.11
- Bleeding is probably the most common complication of this procedure and usually can be well controlled with direct pressure. If hemostasis is not obtained with direct pressure alone, either silver nitrate cauterization or a figure-of-eight stitch with an absorbable suture can be used.
- Infection rate is not known but is believed to be less than 5%. Prophylactic antibiotics are not routinely indicated.
- Perianal skin tag is a common benign complication after the incised area has healed.
- Stricture is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
- Incontinence is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
- Pain is a common but avoidable complication. Any combination of parenteral and local anesthesia with or without procedural sedation may be used to avoid pain completely during this procedure.
- 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 out.
- 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.)
- Patient should begin taking some type of stool softener to avoid traumatic passage of feces. This should be continued for 2-4 weeks.
- Acetaminophen or ibuprofen should be prescribed for pain control. Avoid opiate analgesics because of constipating and, thus, stool-hardening effects.
- Antibiotics are not necessary.
- A wound check is necessary if pain or bleeding persists for more than 36-48 hours postprocedure.
National Institute of Diabetes and Digestive and Kidney Disease, NIH: Hemorrhoids National Library of Medicine, NIH: Hemorrhoids
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Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position). |
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Local anesthesia injected at hemorrhoid base and within the hemorrhoid. |
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Application of povidone-iodine (Betadine) antiseptic. |
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Primary elliptical incision over hemorrhoid. |
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Thrombosed hemorrhoid. Image courtesy of Dr. Jonathan Adler. This thrombosed hemorrhoid was treated by incision and removal of clot. |
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Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc. |
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Thrombosed External Hemorrhoid Excision excerpt Article Last Updated: Sep 18, 2008
Topic originally published: Mar 19, 2007
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