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It is one of the most problematic and least talked about conditions. It can make the life of the person who has it difficult, but it can also complicate it.
Also, since people are embarrassed to talk about it and prefer to remain silent, complications are not so rare. Most people consult for difficulty, not for a hemorrhoidal attack.
Hemorrhoidal thrombosis is one of the most common complications of hemorrhoidal disease. As soon as the diagnosis is made, one quickly hears the incision and excision. Although these are medical terms, this does not necessarily mean the mandatory passage to blockage and general anesthesia.
To understand what hemorrhoidal thrombosis is, you must first understand its condition and have a clear idea of what it has. The doctor told him about hemorrhoidal thrombosis but did not have time to explain the years of medicine in a few minutes, and when leaving the office, he was still confused.
What is a thrombosed hemorrhoid?
When one suffers from hemorrhoidal disorders, blood circulates poorly in the anal region and tends to stagnate. Imagine that it is water with the earth that rushes and stagnates. At some point, it solidifies to form rocks. It is the same principle as thrombosis.
External hemorrhoids occur distal to the dentate line and develop due to enlargement and swelling of the external hemorrhoidal venous system.
A thrombosed hernia occurs when a blood clot forms inside a hemorrhoid. This condition is not dangerous, but it can be painful.
Thrombosed external hemorrhoids are a common problem, but they are still a little-studied topic. The reported risk factors for thrombosed external hemorrhoids include a recent episode of constipation and traumatic vaginal delivery.
Although non-surgical conservative treatment (fecal softeners, increased dietary fiber, increased fluid intake, hot baths, analgesia) ultimately improves most patients’ symptomatology, surgical excision of the thrombosed external hemorrhoid often causes the resolution precipitates.
Newer conservative treatments, such as topical nifedipine, promise advantages over traditional conventional therapies, such as lidocaine ointment. However, compared to surgical excision, it has not yet been shown to shorten the time to resolution of symptoms or reduce the recurrence frequency.
The surgical removal of acute thrombosed external hemorrhoid is within the purview of an office or emergency professional. This safe procedure offers low recurrence rates and complications and high levels of patient acceptance and satisfaction.
Thrombosed hemorrhoids vs. Regular hemorrhoids
There are two types of hemorrhoids:
- Internal hemorrhoids are inside your rectum.
- External hemorrhoids are outside or around your anus.
In general, thrombosis mainly affects external hemorrhoids, but it may be of internal origin.
Patients with external hemorrhoids usually complain of a painful, suddenly appearing anal bulge, which may become severe in severity. It will appear purple and is inside the anal canal.
It may have been precipitated by exertion during defecation, heavy lifting, or pregnancy, but, in most cases, there will be no actual precedent event.
External hemorrhoidal swelling is caused by thrombosis of the venous complex. It is susceptible to palpation and usually does not bleed unless there is an erosion of the overlying skin.
Patients with internal hemorrhoids usually seek help because of a bright, painless (or almost painless) red bleeding during or after defecation.
Patients usually notice intermittent spots on toilet paper or blood that drips into the toilet bowl or both. The blood may mix with the stool or scratch it.
A prolapsed internal hemorrhoid appears as a protrusion of moist, painless red tissue covered with rectal mucosa at the anal border.
Internal hemorrhoids can become strangulated and thrombosed and therefore painful. Itching is not a common symptom of hemorrhoids.
What are the symptoms?
The blood stagnates and creates what is called a blood clot. Blood clots can block the vein and keep blood from circulating, like a rock in a duct.
The blood then begins to collect and creates a pocket. As the thread tends to expand, the wall extends, making the bag accept that we are talking about the anal area here, which is highly innervated. Thrombosis causes very high pain, and you see a blue ball that can be extremely painful to touch.
The swelling of a hemorrhoidal vessel can allow blood to accumulate and subsequently coagulate; This leads to acute thrombosed hemorrhoids, a bluish-violaceous discoloration often accompanied by intense disabling pain.
Other symptoms of hemorrhoids include:
- Itching around your anus.
- Bleeding when you have a bowel movement
- Swelling or a lump around your anus
If you have a fever and pain and swelling, you may have an area of infection called an abscess.
When symptoms begin to appear, the patient will not have time to ask what it is and consult very quickly. That said, everyone reacts differently.
Pain is the most prominent symptom of hemorrhoidal thrombosis, but it remains highly subjective as a sign. Most people report acute pain and a brutal configuration.
However, pain tolerance varies from one person to another, and what a person considers extremely painful can be a bit embarrassing for another person or people with sensory disabilities.
We notice a bump, a blue ball, very annoying and extremely painful that disappears temporarily after going to the bathroom.
The most important thing to remember is that hemorrhoidal thrombosis is a complication of hemorrhoidal disease and is an urgent need for treatment as quickly as possible to prevent symptoms from worsening.
It should be understood that a hemorrhoidal thrombosis evolves spontaneously towards healing. Therefore, if one follows the strict hygiene of life, one can avoid them. The problem can also be remedied before the complication occurs.
What causes thrombosed hemorrhoids?
The causes of thrombosed hemorrhoids are not always identifiable. Some possible triggering events the causes of this pressure include:
- Strive while evacuating, especially if you are constipated.
- Diarrhea.
- Irregular bowel movements
- Pregnancy, by the force of the baby that presses the veins or pushes during childbirth.
- Sit for an extended period, such as during a long trip by car, train, or plane.
Doctors do not know why some people develop blood clots in their hemorrhoids.
What are the risks?
You are more likely to have hemorrhoids if:
- They are constipated because they do not get enough fiber in their diet or because of a medical condition.
- They are pregnant.
- They often sit for long periods of time.
- They are older because aging can weaken the tissues that keep hemorrhoids in place.
Treatments
In some cases, hemorrhoidal thrombosis begins as a hemorrhoidal attack. Take painkillers and anti-inflammatories to relieve the discomfort caused by their appearance. It is necessary to change your hygiene of life and do baths on the seat to reduce the pain.
However, with all the testaments you can demonstrate, hemorrhoidal thrombosis may persist, and in this case, you should not hesitate to consider using invasive treatments with your doctor. We are talking here about the incision and removing a hemorrhoidal thrombosis.
Most thrombosed hemorrhoids will resolve independently, although they can go from two to three weeks until they disappear entirely. Self-care measures for a thrombosed hemorrhoid include:
- Taking sitz baths.
- Working to keep stools soft.
- Avoiding straining during bowel movements.
Your doctor can prescribe some topical preparations that may be useful. Surgery is an option for cases where there is much bleeding and the pain is quite severe. If surgery is performed, it will be removed—all the blood clots.
Interestingly, some researchers would like to rename thrombosed hemorrhoids as “perianal thrombosis” since the tissue involved may not necessarily be that of a hemorrhoid.
Acute pain and thrombosis of external hemorrhoids within 48-72 hours of onset indicate excision.
In a retrospective study, surgical treatment resulted in a much faster resolution of symptoms (3.9 days vs. 24 days), as well as a lower frequency of recurrence (6.3 vs. 25.4%) in the population study.
Another study showed that compared with a simple incision or ointment of 0.2% glycerin trinitrate applied topically, the thrombosed excision of external hemorrhoids improved recurrence rates, symptoms, and residual skin marks at one-year follow-up.
Surgeries for thrombosed hemorrhoids:
Several surgical techniques can be used if conservative management and simple procedures fail. All surgical treatments are associated with complications that include bleeding, infection, anal stenosis, and urinary retention due to the rectum’s proximity to the nerves that supply the bladder.
In addition, there is a small risk of fecal incontinence, remarkably fluid, with rates reported between 0% and 28%.
Ectropion mucosa is another condition that can occur after hemorrhoidectomy (often with anal stricture). This is where the anal mucosa is evoked from the anus, similar to a very mild form of rectal prolapse.
Excisional hemorrhoidectomy is a surgical excision of hemorrhoids used mainly only in severe cases. It is associated with significant postoperative pain and usually requires 2 to 4 weeks for recovery.
However, the long-term benefit is more significant in those with hemorrhoids grade 3 compared to RBL.
It is the recommended treatment in those with thrombosed external hemorrhoids if it is done within 24-72 hours. The glyceryl trinitrate ointment after the procedure helps both pain and healing.
Doppler-guided transanal hemorrhoidal dearterialization is a minimally invasive treatment that precisely uses an ultrasound Doppler to locate the arterial blood flow.
These arteries are “tied,” and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications than a hemorrhoidectomy.
Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue to its normal anatomical position.
It is usually less painful and is associated with faster healing than the complete elimination of hemorrhoids.
However, the likelihood of symptomatic hemorrhoids returning is more significant than conventional hemorrhoidectomy, so it is usually only recommended for grade 2 or 3 diseases.
Incision of hemorrhoidal thrombosis:
The incision of a hemorrhoidal thrombosis is making an incision in the thrombosis to evacuate the clot or clots to relieve the patient.
The incision is mainly for patients with one or more visible and palpable clots.
However, this becomes unnecessary if the medical treatment can relieve and cure, useless and confusing if the clot recedes several weeks, and is utterly impossible if the thrombosis is external circular; it invades the entire anal area.
All the year, it is rare, but it can happen if it is internal and prolapsed. Therefore it is not visible and palpable, or if it is edematous, in this last case, the realization of the gesture becomes technically impossible.
Since this is a very minimal gesture, the complications are minimal. Minor bleeding may occur but will soon be mastered by the doctor because the incision will not be deep enough to cause significant bleeding.
The only significant risk may lie in a possible allergy to local anesthesia. However, it is relatively rare, and the doctor will have in his office the necessary equipment to obtain first aid while waiting to take it to a specific environment.
Even if we call this an operation, it can happen in a doctor’s office, a non-specialized environment. It is the process of extracting a wisdom tooth without the need for general anesthesia.
The specialist doctor proceeds to install him comfortably on his side, in lateral decubitus, as he is called in the medical jargon. He will ask him to hold his gluteus or resort to external help to expose the area well.
After a painless local anesthetic injection, it will do so after gently disinfecting the area. Your gestures will be gentle to avoid hurting you. The needle is tiny because the injection is subcutaneous. It is like the insulin needle that people with diabetes use alone at home.
You will only feel slight pressure when injecting and then nothing. This is where the doctor will proceed with the incision with a scalpel to remove the clot. Since the incision is small enough, you will not have stitches and go home without pain!
After the incision, you should make sure to make a toilet with a neutral soap to avoid a very frightening infection due to the scar’s location.
You will also have simple protection with a compress for a few days and possibly a healing ointment or anti-hemorrhoids. It is also essential to make sure that the cause of the problem is resolved to avoid recidivism.
It is also necessary to rest and take analgesics when the crisis is over and NSAIDs (non-steroidal anti-inflammatory drugs: corticosteroids). If the pain persists with the same intensity after two days, it is necessary to consult urgently.
Removal of thrombosed hemorrhoids:
The excision is the removal of the entire thrombosed hemorrhoidal sac.
That is to say, unlike the incision of the hemorrhoidal thrombosis, one not only cuts and eliminates the clot but also eliminates everything that is around.
As for the incision, excision is suggested in case of painful thrombosis, which does not respond to pharmacological treatment.
This treatment is also reserved for external, non-edematous thromboses, which do not respond to pharmacological therapy.
It is not indicated for people with anticoagulants due to the significant risk of bleeding and people with Crohn’s disease due to the equally crucial infectious risk.
The preparation is precisely like the incision; only the “incision” technique changes. In fact, instead of the scalpel, we proceed with scissors, and the wound is much broader to avoid any folding that may lead to seafood. The clot is removed in the vascular sac to prevent a recurrence.
Contraindications
The absolute contraindications for thrombosed external hemorrhoidal excision in the emergency department (ED) include the following:
- Any concern that the injury may be anything other than thrombosed external hemorrhoids, such as a painless rectal mass (thrombosed external hemorrhoids are always painful).
- An internal grade IV hemorrhoid is associated with a thrombosed external hemorrhoid.
- Severe known coagulopathy.
- Hemodynamic instability.
The contraindications related to the excision in the emergency department of a thrombosed external hemorrhoid include the following:
- Allergy to local anesthesia.
- Perianal infection.
- Figura anorectal.
- Portal hypertension.
- Inflammatory bowel disease
- Known coagulopathy.
- Any systemic severe disease or comorbidity would significantly increase the risk of the procedure.
